The Interconnections Between Public Health and the Global Eradication of Smallpox

Thomas Summers

Based on the novel Smallpox—The Death of a Disease: The Inside Story of Eradicating a Worldwide Killer

Biol 101 Professor James 6 August 2012


D. A. infecting billions of humans and killing approximately one third of those who contracted it. Henderson begins his narrative with a detailed history of smallpox and its role in humankind. throughout southeastern Asia. numerous Hindu shrines devoted to the smallpox goddess Sitala Mata were built. Henderson’s book Smallpox—The Death of a Disease: The Inside Story of Eradicating a Worldwide Killer brings a behind-the-scenes look into the global campaign to eliminate smallpox. the lessons learned through its existence and eradication continue to be an integral part in modern public health. Those who survived the disease were often left blind or disfigured with scars and pocks. A. The mysterious communicability of the smallpox disease was expressed in societal structure as people created gods and goddesses representing smallpox. For fourteen years the global campaign fought the disease.” 2 . For millennia smallpox circulated the globe. a program for eradicating smallpox was initiated in 1967by the World Health Organization. as shown through mummified bodies and Sanskrit medical records. With the rise of the Greek and Roman empires came several outbreaks of smallpox.000 BCE. While smallpox is no longer widespread. It distinctively emerged in ancient urban civilizations in Egypt and Asia. Smallpox is believed to have arisen with the development of agricultural communities in 14. for example. D. transmitting from person to person as it is unable to infect other animal species.Summers The eradication of smallpox remains one of man’s greatest feats within the field of public health. examining the countless obstacles faced throughout the fourteen year battle. the two most devastating epidemics were recorded as the “Plague of Athens” and the “Plague of Antonius. Despite the doubts of many national health leaders and ministers. ending with the final indigenous case in 1977 and the program officially concluding in 1980.

this decrease may be attributed to better health services and more potent vaccines. enabling it to become an endemic disease across Asia. With the vast urban growth of the tenth and eleventh centuries. As the disease transferred among the communities. Leslie Collier developed a freeze-drying method to produce a heat-stable smallpox vaccine. the survivors developed a permanent immunity to smallpox. Even though variolation and vaccination methods began decreasing the number of cases. Dr. Edward Jenner. The technique of vaccination was first introduced in 1796 by the English physician Dr. In the early 1900s the number of smallpox cases in industrialized countries substantially decreased. with its success in smallpox prevention. however. sweat therapies. techniques including use of herbs. smallpox continued to be serious problem until around the mid-1920s. Prevention and treatment measures varied from culture to culture. and erythrotherapy. Variolation with infected pustules began in India and. the assembly accepted the proposal for a global scale program for eliminating smallpox. the proposal was rejected. many believing such a feat to be ecologically and economically impossible. bleeding. the plagues of smallpox in ancient societies did not tend to last for extensive periods. By the late 1940s. At the time the assembly agreed to a global campaign. Early colonial America was not large enough to sustain an unbroken smallpox transmission. and Africa. smallpox was able to continuously circulate among a given population. though it did experience epidemics every seven to ten years. The proposal was later brought before the 1959 World Health Assembly and. noxious chemicals. and gradually the infection would die out as fewer vulnerable hosts remained. spread to China and Europe. With the availability of a heat-stable smallpox vaccine and North America free of smallpox through organized vaccination programs. a proposal was presented before the World Health Assembly for global eradication of smallpox in 1953. though more political coercion rather than scientific agreement.Summers However. fifty-nine countries 3 . Europe.

mass vaccination programs were implemented. vaccinations were administered in needed locations and the last case of smallpox in Brazil was found in March of 1971. Nepal. yielding an ineffective reporting system. it took more than four years. Through this new approach. The country reported a few thousand cases each year. Progress with the mass vaccinations was disappointing. Poor vaccines combined with poor vaccination supervision led to thousands of men and women still susceptible to smallpox outbreaks. Rather than improve surveillance of the disease. though. however. but in reality it was probably many times that number. Afghanistan. India.465 cases to the country’s number. and the civilians considered the disease to be no more serious than chickenpox.Summers were endemic to smallpox. Indonesia. Nevertheless. The weaker smallpox virus Variola minor was the only form present in Brazil. The epidemiologists revealed the need for effective reporting and the program was transformed to include a strong surveillance program. in the end. three epidemiologists were assigned to conduct surveillance on the progress of the smallpox campaign. rendering poor vaccines. their data added an additional 1. For the eradication program in Indonesia. thirty-one countries were endemic: Brazil. Pakistan. standardized reporting forms allowed outbreaks to be efficiently documented. and nearly all of the sub-Saharan African countries. Eradicating smallpox in Brazil was expected to take only a couple of years. Collecting these data for an overall surveillance report. In 1969. creative methods for transporting the documents were found by hiring 4 . By the time the eradication program began in 1967. proved to be difficult due to the country’s numerous islands and isolated colonies. The Brazilian vaccine repetitively failed to meet global standards for potency and heat stability. surveillance-containment methods were incorporated early in the program. Lack of public interest led to lack of disease reporting. Within the Indonesian system.

military personnel. famines. The last case occurred in January of 1972. or resources provided towards Indonesia’s eradication program. Through the collected data and targeted vaccination. every country either had endemic smallpox or bordered a country with endemic smallpox. Indonesia’s smallpox campaign also provided the global program with another aid: the Smallpox Clinical Recognition Card. and traveling businessmen. In addition to showing the world that smallpox eradication is possible and developing the strategy of offering a reward for outbreak notification. with their knowledge of village affairs. directed surveillance crew to the villagers afflicted with smallpox. the number of smallpox cases dropped to only a few. Many of the African countries were covered with either dense uncharted tropical rainforests or flat barren lands with no noticeable landmarks. the cards were brought to schools and shown to the students and teachers. and a severe lack of 5 . Developed by an Indonesian surveillance worker. The incentive successfully allowed the remaining smallpox outbreaks to be immediately found and treated. The recognition cards contained pictures of children afflicted with the diseases pustules and pocks. transportation methods. a little less than four years after the program began—an impressive accomplishment considering the lack of substantial funding. Similar to the Indonesia. This technique was crucial to the overall eradication of smallpox as it decreased time taken to locate outbreaks compared to door-to-door searches.Summers the help of bus drivers. These cards were eventually mass distributed to staff and used around the world in the attempt to eliminate smallpox. poor roads. Additionally. unpredictable political conflict. The children had little difficulty in recognizing the disease and. Combining these obstacles with civil strife. the African campaign faced many difficulties due to geography. refugee camps. and the Indonesian government instigated a new strategy: offer a reward for reporting any remaining smallpox cases.

roads. primarily due to civil war expenses. a teaching program was implemented training the vaccinators on many topics. this in turn led to successful vaccination programs and a rapid elimination in smallpox infections. before the volunteers were able to be shipped to Africa. resources. nevertheless. the countries in eastern and southern Africa required only a mass vaccination program. the countries managed to maintain ongoing vaccination programs and gradually smallpox was eradicated from the southern end of Africa. 6 . East African countries generally possessed better health services. Once all of the vaccination plans. and an intensive crash course on the history and customs of West African countries. This training molded the vaccinators to fit their environment. and advisory personnel were arranged. enabling better cooperation between the volunteers and the African communities. country agreements. West African smallpox eradication began in 1965 before the 1966 World Health Assembly decision to globally wipe out smallpox. they needed training in working within the African environments. Cultural tailoring combined with the surveillance-containment method (labeled “EradicationEscalation”) accelerated the eradication of smallpox in West Africa. and communication compared to those in West Africa.Summers health resources. repairing vehicles with limited parts. speaking French. including identifying and treating smallpox. Southern Africa never possessed all of the resources for a surveillance program. and with the limited resources available. As such. recruitment for volunteer vaccinators was conducted. it is extraordinary that the entire continent—except for Ethiopia and Botswana —was free from smallpox just five years after the African eradication program began. While most countries required a surveillance-containment method of vaccination in order to overcome the smallpox epidemics. However. among the cultures. fixing the new vaccine jet injectors. The last case occurred in 1970 and the West African program was completed both ahead of schedule and under budget.

though. but it would not be until 1975 when the disease was officially eliminated from the country. All of the refugee camps were vaccinated by WHO volunteers except for one: Salt Lake Camp. the mass vaccinations did not reduce the number of smallpox epidemics. Despite the sudden increase in cases. Unfortunately. The national program for India’s smallpox eradication began in 1962. especially since the disease has been part of the culture for so long (as shown by the ancient temples devoted to Sitala Mata. though. many believed that smallpox would never be completely eradicated from India. painful rotary lancets rather than bifurcated needles to administer the vaccines. further improving the reporting system and forcing the use of the bifurcated needle as the method 7 . With a dense population of 550 million people. the Indian government began withdrawing funds until 1970 when the program was reformed to a surveillance-containment method rather than mass vaccination. Bangladesh had declared its independence from Pakistan and thousands of refugees had left the camp to return home.Summers Out of all reported cases in the world. but the vaccinators were still using traditional. Refugees fled to India and many were housed in refugee camps. Smallpox broke out within the camp and went undiagnosed for two months. The smallpox epidemics in India began decreasing until 1971 when civil war broke out in the nearby country Bangladesh. the Hindu goddess of smallpox). When it was finally diagnosed. skyrocketing the number of smallpox cases in both India and Bangladesh once more. vaccinating 440 million people over a four year period. Due to the lack of success. Vaccine quality had slightly increased with the use of freeze-dried vaccine. The refugees brought smallpox back home to both Bangladesh and West Bengal. the eradication program continued to develop. it was too late. India’s people accounted for more than half of the total number. The campaign began with an impressive start.

and Bangladesh all had expansive an inexpensive public transport which were well used by their people. villageby-village searches. This interconnecting web. and a national celebration was held on August 15 celebrating the elimination of smallpox in India. while a benefit economically. the government began offering a reward for reporting any last smallpox cases. Similar to India. Posters displaying a classic Indian Hero slaying a smallpox demon were distributed to rally public support for the final stages of the eradication campaign. providing food and stipends to further keep the infected families at home rather than on the streets. The Indian programs also began utilizing guards to quarantine those who were infected. Afghanistan. Mass vaccinations and surveillance once again brought the epidemics down to small numbers. and firm containment measures until the last outbreak in 1974. By early 1975.Summers of vaccine distribution. Further. Converting the variolators into vaccinators accelerated the elimination of smallpox in Afghanistan. civil war broke out in 1971 and the return of refugees also brought back the return of smallpox to the country. but in 1974. Thus. Bangladesh had managed to eradicate smallpox in 1970. Mass vaccinations were the initial strategy utilized. However. heavy monsoon rains and floods destroyed crops. utilized surveillance systems early in the program and discovered that many of their outbreaks began from variolators. the three countries Afghanistan. and the last endemic case occurred in September of 1972—only thirty-six months after the program began. bringing famine and infected refugees. Through mass vaccination and surveillance-containment measures. the 8 . Pakistan eventually abandoned mass vaccination and began surveillance-containment operations. though. Pakistan. Bangladesh was the last country in Asia with smallpox. but the programs failed due to poor health resources and inadequate program management. enabled smallpox to spread frequently and more extensively than in other lands such as Brazil or Africa.

Surveillance revealed there to be over one thousand cases hidden within the country.Summers Bangladesh government decided to bulldoze the land where the refugees were staying. and vaccination resistance. With smallpox eliminated from South America and Asia. More stringent surveillance and containment methods were implemented and eventually smallpox was officially eradicated from Bangladesh (and Asia) in January of 1976. More epidemiologists and volunteer vaccinators were brought once again for surveillance and containment procedures. Mass vaccination and surveillance-containment immediately began until the final case of smallpox was discovered on October 31. the country only possessed the mild Variola minor virus so the communities did not find it necessary to eradicate. Unknown to the rest of the world. this scattered the refugees and. 1977. The last case was Ali Maalin. It was believed Somalia was smallpox-free throughout the global campaign until cases of smallpox began arising in the country after Ethiopia’s program ended. the remaining endemic country in the world was Ethiopia. poor roads. Somalia was infected with smallpox. yet smallpox was not yet eradicated from Africa. a twenty-three year old cook in the port town of Merca. For one. the Ethiopians did not fear the smallpox disease. endangering the vaccination volunteers as some were captured and temporarily held hostage. On top of all of this. Ethiopia managed to be free of smallpox by the summer of 1976. scattered the smallpox once more across the country. in turn. Most of the people in Ethiopia were also unwilling to be vaccinated so it took bribing and use of the jet injector to vaccinate the population. 9 . The absence of decent roads and maps further impeded the eradication as proper surveillance was unable to be conducted. From the beginning the Ethiopian campaign faltered and faced multiple dilemmas. battles broke out among the lands. In spite of civil unrest.

and tuberculosis. leprosy. it continues to be a concern on topics such as antiviral drug research and bioweapons—especially after the anthrax scare of 2001. malaria. some negative (bioweapons) and some positive (possible eradication of polio). studies. as many countries are working together to counter other diseases such as HIV/AIDS.” 10 . the World Health Assembly certified the world to be officially free from smallpox. As D. “New generations of public health staff inherit a world of extraordinary challenge and opportunity. The importance of cultural tailoring. A. Even though smallpox is currently only kept in a laboratory. the need for support not only on the government level but on the community level. Henderson’s concluding theme is true. these are some of the many lessons learned through the global eradication of smallpox. largely due to the developments discovered during the smallpox eradication campaign. the depth of public health continues to expand. the importance of transportation and communication.Summers On May 8. the application of simpler vaccination methods. 1980. the necessity for surveillance. Smallpox—The Death of a Disease concludes with the theme that public health is rapidly changing due to innovative research and dedicated scientists. Henderson notes. Numerous smallpox vaccination factories and smallpox labs were shut down. and medicines are developed. The success of this campaign has inspired more events to take place. Dr. and only two labs continue to contain live smallpox virus: one in Russia and one in the United States of America. techniques. The field of public health is rapidly growing. the consequences of removing a factor in a worldwide ecosystem. too. As more research. International public health has developed.

Sign up to vote on this title
UsefulNot useful