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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-specicantibody testing available at that timewas unreliable. Nevertheless, by May1980, the monkeypox surveillanceprogramme was well underway.
Operational complexitiesabounded, and there wasconict 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 experiencedocers. 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 rainorestregions. Serological surveillancewas also conducted in Zaire in areaswith the highest incidence o humanmonkeypox, mostly by collecting serarom 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 byrequent changes in research prioritiesand tactics, as the ecacy o particularstrategies, and their implementation indierent localities, was much debated.The response o Zaire’s citizens,local health ocials and governmentocers to the growing WHOpresence is not well documentedin the Geneva archives. The WHOdid make an eort in 1980–81 topersonalise the country-specicsurveillance programmes in western Arica. 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 unsuitableor the Zairian nursing sta to whomthe protocol was distributed.Operational complexities in Zaireabounded, and there was conict 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 thereorenot useul or compensation. By 1985, WHO eld teams had adopted a ormo currency that was both practical andhighly eective: 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 eldocers were immediately instructedto use only local currency, much tothe dismay o the research team. While eld research in central andwest Arica struggled to get underway,scientic 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 responsibleor the controversial ndings. WHOscientists have more recently suggestedthat Soviet interest in variola virusand monkeypox research may havebeen prompted in part by Sovieteorts to weaponise orthopoxviruses,and the whitepox ndings may havebeen deliberately abricated.Dumbell’s conclusions and thescientic community’s subsequentdismissal o the whitepox threat mark a major turning-point in the languageused by the WHO to justiy themonkeypox surveillance programme’sactivities. By 1983, WHO committeeworking papers reerred not to thethreat o smallpox recurrence butto helping Arican nations manageoutbreaks o human monkeypox.Tragically, it would be a dierent viralinection that would cause Arica’s nextpublic health crisis. In 1986, the WHOCommittee on Orthopoxvirus Inectionsdecided that the human monkeypoxprogramme should be discontinuedin light o the new research priority incentral and west Arica: HIV/AIDS.Sporadic cases o humanmonkeypox inection continuedin central and west Arica ater theconclusion o the active surveillanceprogramme. Signicant 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 inections occurred in themidwestern USA in 2003, associatedwith exposure to inected prairiedogs; the outbreak was traced to theimportation o small mammals rom Arica. 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 condent 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.
Arica, but never a major killer.