Overview
Smallpox’s eradication changed world history through ending one of the greatest causes of death in human history, bringing the world closer through international cooperation. The end of smallpox in 1980 was the culmination of over two centuries of medical work and decades of international testing and cooperation.
What is Smallpox?
Smallpox, (also referred to as variola major or minor (VARV) in medical circles), is a contagious virus in the orthopoxvirus family. It spreads through airborne droplets and skin to skin contact. The disease is highly lethal when contracted. About 3 out of 10 people who contracted smallpox would die, and every survivor would be left with scars from the lesions that appeared all over the body. These lesions are not just limited to the outer skin layers, but also appear inside the body, most notably in the pharynx, larynx and trachea, complicating breathing and inviting lung inflammation, otherwise known as pneumonitis. While smallpox is most recognizable by its lesions, the disease also resembles that of a flu, exhibiting much of the same symptoms but on a more intensive scale.
Prior to the establishment of the smallpox vaccine, natural medicine and radical exposure techniques were used to contain the spread of smallpox. One such method, developed in 10th century China, was variolation (also known as inoculation). Variolation involved grinding up smallpox scabs into a fine powder, which would be inhaled or scratched into the person's arm in order for the person to develop an immunity to smallpox. The technique of variolation was widespread in Asia and Africa, however, countries in Europe denied its validity. This changed in 1716 with the inoculation of the child of Sir Edward Montagu, the British ambassador to the Ottoman Empire, whose wife later spread the practice to the British Isles and most of Europe.
The Beginning of the End
The introduction of variolation to the European continent allowed for Europeans to mitigate smallpox outbreaks. Initially, the movement was slow to take hold, with the aristocracy voicing their discontent against variolation. However, after various physicians and men of standing witnessed variolation’s successes in Africa and Constantinople, and after the Princess of Wales inoculated herself and her children against smallpox, inoculation soon was accepted in scholarly and physician circles. Inoculation later spread to Russia, where the practice was popularized by Catherine II, and later to the rest of Europe, with conservative French medical practitioners being the last to accept it.
However, complications still persisted with inoculation. While it did have a lessened risk of death, around 3% of those inoculated would still die of the disease. This was certainly an improvement from the 30% death rate of those without inoculation, but it was still far from perfect. Furthermore, symptoms of smallpox were similar to chickenpox, resulting in scabs for smallpox inoculation being taken from chickenpox victims instead. Unfortunately, Europe lacked another method to combat smallpox until the 1790s. In the 1970s, physician Edward Jenner realized that milk maids, after having contracted cowpox from their cows, a significantly less lethal disease, never contracted smallpox in their lifetimes. Armed with this knowledge, he infected a boy with cowpox, and after a short recovery period, with smallpox. The result was astounding – the boy did not develop any symptoms of smallpox.
Having taken insight from his peers in medical institutions across England, Jenner came to the conclusion that cowpox would protect an individual from smallpox, offering a safer and more effective method compared to inoculation. Jenner dubbed this method as the vaccine to smallpox and documented the discovery. Soon, vaccination would encompass Europe and the Western Hemisphere, with its effectiveness being heavily documented across European medical journals and newspapers by the end of the 19th century. In places like Sweden and the UK, smallpox deaths fell to 155 and 26 deaths per million, respectively. On the contrary, in places where vaccination was lacking traction, most notably Russia and Spain, the mortality rate remained at pre-vaccine levels. Overall, smallpox fell from being the top killer of Europeans to being one of the most insignificant. Unfortunately, the African continent continued to suffer from outbreaks of smallpox. Having been neglected by early vaccination efforts, Africa continued to be a hotbed of activity for smallpox throughout the 19th and into the 20th centuries.
The End of a New Beginning
As the world progressed through the 20th century, smallpox continued to be contained in Europe, but devastatingly ravaged the developing world. In Africa, where vaccination efforts occurred on a smaller scale due to the remoteness of population centers. People continued to suffer from the disease, with case numbers only being surpassed by population-dense nations like Pakistan and India. Efforts were still made to vaccinate the colonial holdings of European powers, but the lack of infrastructure reduced the effectiveness of these vaccination programs. program. Similarly, developing nations in the Middle East only saw limited success in the containment of outbreaks due to the lack of vaccines and the more widespread practice of inoculation. With the presence of smallpox in these nations, its threat could not wholly recede from the world. Smallpox lingered in the areas of the world where vaccination was unavailable for the common populace and where proper medical treatment and care was either unaffordable or simply out of reach, typically places of the world that were remote, underdeveloped, and poverty stricken.
After World War II, the world came together to form the United Nations (UN) to promote international unity and cooperation, preventing a repeat of the tragic events of the war. Along with the formation of the UN came the formation of the WHO, an organization under the UN’s auspices created to promote world health and contain threats to world safety in medicine and disease control.
The WHO, being divided into regions based on geographic location and cultural lines, often was influenced by international politics. Regardless, it was tasked to preside over health management and containment of epidemics. Unfortunately, in the early years of the WHO,, the organization was tormented by political divides from the immense tensions of the Cold War. These politics resulted in the WHO’s loss of the Soviet Union and the entire Eastern European Communist bloc. With the departure of the USSR, the WHO was dominated by U.S system of technical assistance, which aimed to provide technology and infrastructure necessary for a developing nation’s medical industry to thrive. In contrast to technical assistance, social medicine was an ideology from a more socialist worldview, that argued that socio-economic factors of capitalism, such as poor and exploitative working conditions, were the causes of pestilence worldwide.
Amidst the sea of ideology and political theory, smallpox continued to haunt humanity. Nations in Africa, which had recently experienced decolonization, still had tremendous outbreaks of the disease, even with the WHO’s doctrine of “technical assistance”. Across the Iron Curtain, however, the USSR did not stand idly by. By the 1950s, it had contained smallpox within its borders thanks to vast, albeit coercive, immunization programs carried out by the government in its efforts to appear more politically legitimate and benevolent in the eyes of its people. Unfortunately, the USSR’s border nations, such as Afghanistan and Iran, continued to experience severe outbreaks of smallpox. Inevitably, spillovers did occur, which were later countered by further immunization programs in the Central Asian SSRs. Specifically, spillovers occurred in the UK with the Bradford outbreak, caused by immigration from smallpox-ridden Pakistan, as well as in the US with the 1950s Mexican immigration wave. These developments initiated further waves of vaccination and led to the issuance of vaccination cards for travel abroad, causing issues with immigration and isolation of patients.
The Final Push
In 1957, the USSR and its republics lifted their boycott of the WHO after nearly a decade of abstinence from its meetings. After reinstating itself into the WHO, Viktor Zhdanov, the USSR’s then deputy health minister, represented the USSR at the 11th WHA (World Health Assembly), where he proposed the eradication of smallpox worldwide through immunization programs and aid to nations suffering from the disease. Zhdanov argued that, out of all the seriously threatening diseases in human history, smallpox was now the easiest one to destroy. This was demonstrated through the successful defense against spillover outbreaks from Afghanistan and Iran in the Central Asian SSRs, despite the lack of significant medical infrastructure in the rural and remote steppes. Zhdanov’s proposition put aside ideology and politics, replacing them with the sheer will of humanity to trump the insurmountable. In a historic moment, on the 12th of June in 1958, the 11th WHA voted unanimously to adopt resolution WHA11.54. This resolution called for an international program connecting the technologies, industries and scientific prowess of the global community to provide what the world needed to eradicate the disease once and for all. While there were concerns about the economic repercussions of the program, they were silenced by the fact that the eradication of smallpox would pay back dozens of times more than what was initially invested, ridding the world of an issue that had plagued it for millenia.
After nearly a decade of preparation, WHA 11.54, the global program to eradicate smallpox, began in 1966. 25 million doses of the smallpox vaccine presented by the USSR were shipped to various third world countries. Furthermore, in 1960, an official, WHO-sanctioned laboratory for the production of smallpox vaccine was opened in Moscow. From 1966 to 1980, over 1.5 billion doses of the smallpox vaccine were produced in the USSR alone. In the fight against smallpox, the main focus points of WHA11.54 were Brazil, India, and African nations, where smallpox was ever present. However, the delivery of vaccines to these nations proved challenging, due to the lack of infrastructure and transportation available.
Thus, WHA11.54 adopted methods to circumvent the issues and cover as much ground as possible. One method was Surveillance and Containment, where people would be questioned if they knew anyone with symptoms of smallpox. If they did not know anyone with symptoms of smallpox, the workers would move on until they did. In cases where someone did have symptoms of smallpox, the workers quarantined the sick and vaccinated the rest of the population. The second method acted as a backup to the first, was dubbed “ring vaccination” where the villages surrounding a village with an outbreak would be vaccinated in order to prevent the outbreak from spreading.
In India, the WHO faced a greater challenge due to its dense population, with many people living in crowded slums. Along with the economic situation, India faced ethnic tensions within its borders, complicating domestic vaccination efforts. Additionally, the Bangladesh Liberation War, caused refugees to flock to India and crowd in camps which made it harder for vaccination efforts to ensue. The proposed solution was to simply go to every household in India and question them in regards to smallpox, which would continue for 5 years, with monetary compensation offered to stimulate participation. This program ultimately proved successful, containing smallpox outbreaks across Southeast Asia.
As a result of such efforts, during the 33rd WHA, on May 8th, 1980, the assembled delegates declared smallpox as an eradicated disease. This marked the culmination of over two centuries of work, research, and international cooperation. Absent the discoveries of Jenner, the vaccine that saved countless generations from the trauma of smallpox would not have existed. Most importantly, absent the cooperation and camaraderie of the WHO, smallpox would still be prominent in our world today. The international community’s cooperation and sense of unity during the Global Eradication Program of smallpox proved to the world what the indomitable human spirit was capable of, and just how far it may yet take humankind.
Works Referenced
Cover Image: From https://en.wikipedia.org/wiki/Smallpox_vaccine.
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