Smallpox

There are currently a some cultures in a few labs scattered around the world. There has been some discussion about whether those cultures should be destroyed, making it possible that smallpox could be forever gone from this planet. However, there are always worries that it may not be gone from nature, and eliminating those cultures could make creating vaccines take a bit longer. There's also the possibility that research on smallpox may have scientific value.

Nobody seems to be in a hurry to destroy those cultures, so there's a good chance it'll stay around for a while longer.

Smallpox is highly communicable, transmitted by infected saliva droplets that are transferred in normal face-to-face contact.

Smallpox's incubation period is about 12 days, and comes on like a the flu: initial symptoms include fever, fatigue, and head- and backache. The rash comes two to three days later. After a week, the skin lesions fill with pus, then they scab over, and they ordinarily separate and fall off in three to four weeks. Often, they leave extensive and easily recognizable scarring.

There is no treatment for smallpox, besides symptomatic relief (replacing lost fluids, medicine to control the fever, and so on). Still, vastly improved sanitary conditions in hospitals make the odds of recovery much better than they used to be; in some communities, smallpox was 90-per-cent fatal.

Vaccination

There is a modern smallpox vaccine, based on the vaccinia virus (from which the word "vaccine" is derived). Vaccinia is a genetic relative of variola, but nowhere near as virulent; fighting through a vaccinia infection provides near-immunity to smallpox. Smallpox vaccination is out of fashion these days because smallpox is not thought to exist in the wild (more on this shortly); vaccinia is fatal in about one person in a thousand, and with the risk of smallpox infection so low, authorities haven't considered it worth the risk. Canada and the U.S. stopped mass vaccinations in 1973; some countries, especially in Africa and Asia, still require it for travellers.

History and eradication

The disease is at least 3,000 years old, with cases confirmed in China, India, and North Africa. Smallpox thrives in dense populations, and became extremely common in Europe in the 17th and 18th century. In the "New World," smallpox was used as a crude bioweapon against native populations; Cortez took the Aztec empire after (probably accidentally) contaminating the natives in Mexico, and settlers in North America deliberately traded smallpox-infected blankets to native populations to weaken them.

In 1967, the World Health Organization (WHO), a United Nations agency, started a mass vaccination campaign; smallpox was killing as many as 15 million people a year. As such diseases go, smallpox is a relatively easy target: there's only one strain, animals don't carry it, and everyone who gets the disease shows symptoms.

The WHO's program was fantastically expensive, but it had the rare Cold-War-era support of both the U.S. and the Soviet Union, plus China and India and the powers of Europe. The WHO was willing to pay for doctors' medical educations if they'd agree to do tours of duty racing around the world, plunging into jungles and climbing mountainsides, immunizing virtually anyone they could find. In some cases, the doctors and nurses with makeshift tents and needle kits were the first representatives of modernity native groups ever encountered. Even so, once the teams explained what they were there to do (not always easy), the people they were there to jab were often remarkably receptive: everyone had seen what smallpox could do.

The last recorded natural case of smallpox was in Somalia in 1977. The WHO declared the disease eradicated in 1980.

The smallpox campaign, incidentally, demonstrated how difficult it is to try to wipe out any disease. Smallpox was easy, relatively speaking, but it still took unprecedented international co-operation, millions of dollars/rubles/pounds/yuan, and 10 years.

Current status

Smallpox is known to exist in cultures in two countries: at the Centers for Disease Control in the United States, and in state biological labs in Russia. There are also probably "weaponized" forms of the virus in states with biological warfare programs. The WHO recommended that the last laboratory cultures be destroyed in 1999, but neither the U.S. nor Russia has complied; they both make the case that if there ever were another outbreak, it would be useful to have samples ready to go.

As a weapon, smallpox is of mixed value: it can cause large numbers of casualties, theoretically, but the long incubation time makes it a strategic, rather than a tactical weapon. Spreading it would be difficult: as soon as the first victims became visibly sick, known isolation and vaccination plans would slam into action. (Soldiers are regularly vaccinated, so smallpox would be of negligible use in a military setting.)

Every so often, the virus "gets loose" in a lab, and there's a localized epidemic. One such incident in the U.S. resulted in the suicides of two scientists who feared their mistakes would be responsible for undoing the success of the eradication campaign.

Smallpox should be as well-known to people as the bubonic plague for its effect on human history. The disease is mentioned in ancient Egyptian writings, circa 3700 B.C., and the mummified body of Ramses V shows the pustules on his skin. A smallpox epidemic in Athens weakened the city shortly before the Peloponnesian War, contributing to Athens' defeat. Smallpox attacked the soldiers of Alexander the Great in India, contributing to his decision to turn back his conquering army. Emperor Marcus Aurelius' death from smallpox probably accelerated the decline of the Roman Empire.

But even greater results from smallpox epidemics was found during the European colonization of the Americas. Europeans were generally more resistant to the disease because of its constant presence in Europe; Native Americans had no resistance at all. In the Caribbean Islands, up to half the Indians died from smallpox brought over by Europeans; this led to the first importations of African slaves, who were more resistant. Hernando Cortes might have been expelled from Mexico by the Aztecs if it were not for the smallpox epidemic that gripped the Aztec capital of Tenochtitlan after the Spaniards' first visit. The disease spread from Mexico down into South America through native traders, and afflicted the Inca civilization, killing Emperor Huayna Capac and his designated heir. The remaining claimants to the throne got into the civil war which allowed Francisco Pizarro the chance to overthrow the entire government.

Enough trading went on in North America that smallpox affected those Indians also. Almost nine-tenths of the native population in the Massachusetts Bay area died of smallpox in the four years before the Pilgrims landed in 1620; Pilgrim leader John Winthrop wrote that "the natives, they are all near dead of the smallpox, so as the Lord hath cleared our title to what we possess." The disease kept spreading into populations that had not been exposed to it; Elizabeth Fenn estimates that in the years 1775-1781, smallpox reached the Comanches, Mandans, Hidatsas, Arikaras, Apaches, Crows, Sioux, Ojibwas, and many other tribes of the North Plains and Northwest Coasts of the U.S. and Canada. Records show that more than 61,500 Native Americans died of smallpox during those seven years in what is now the U.S. and Canada (possibly many more, since that total is based only on surviving records). During the same years, the region that is now Mexico recorded at least 46,000 deaths from the disease (this includes anyone who had been baptized Christian, whatever their racial background).

Colonists of European descent were nearly as vulnerable as Indians after a generation or so in the New World, where smallpox tended to sweep through the population every twenty years or so rather than being as endemic as it was in much of the Old World. During the American Revolution, the British were accused by the colonists of intentionally spreading the disease in the besieged city of Boston right before the British abandoned the area in March 1776. Smallpox-weakened forces were definitely one cause of the failure of the U.S. attack on Quebec around the same time.

The contagious nature of smallpox was well-known in any area that had experienced it. Smallpox cannot be transmitted through animals, but the virus is present in an infected person's saliva, mucus, urine, pus, and blood. So it can be spread through sneezing, coughing, or talking, but also even coming in contact with dried pus or scabs from pustules could pass along the disease (laundry workers handling bed linens from smallpox wards were at great risk of coming down with the disease). Quarantine was the favored solution, though it often left the sick unable to help themselves without enough health workers who had already had the disease.

Variolation (sometimes called inoculation) was practiced in some areas. This was the practice of deliberately infecting people with the disease through a scratch in the skin; acquiring it this way seemed to lead to milder cases of the disease than catching it naturally by breathing it in (the fatality rate dropped from 30% to 1%). This idea seems to have been invented in India, spread both east and west from there, and was brought to Europe by Lady Mary Wortley Montagu, wife of the British ambassador to Constantinople, in 1718. Anyone who has actually had smallpox, either naturally or through variolation, is immune for life, and this was a powerful incentive for many to undergo variolation. Others, though, refused to go and catch a possibly deadly disease on purpose. Another problem with variolation was that the mild cases might lead people to return to their normal activities while they were still infectious; the people who caught it from them would not have a mild case.

In 1796, Dr. Edward Jenner was doing research on cowpox, a mild disease humans can catch from cows, and its relation to smallpox; milkmaids who had had cowpox never seemed to catch smallpox. He inoculated an eight-year-old boy with cowpox, and one month later with smallpox. The child proved immune to smallpox, and two years later after more research Jenner published his results. This started the era of vaccination, though for the next century it proved difficult to keep cowpox samples available with which to give vaccinations. It also turned out that smallpox vaccination did not offer lifelong immunity, but only about a decade's worth. (This is still the case with modern smallpox vaccine.) Some people, especially those with compromised immune systems, also have serious reactions to the vaccine.

Smallpox was still causing an estimated two million deaths per year in the 1960s. Freeze-dried vaccines supplied by developed countries and a special needle used for vaccinations made it easier to vaccinate in rural areas of developing countries, and the World Health Organization went on a campaign to eradicate the disease, which finally became a reality in 1980. But this only made it more dangerous in many ways, as supplies of vaccine have dropped and medical personnel now assume smallpox could not be a possible diagnosis. Officially, all samples of the smallpox viruses have been either destroyed or sent to one of the two remaining stashes in the United States and Russia. The Soviet Union was revealed in 1992 to have been working with the smallpox and related viruses as agents of biological warfare; this was revealed by Kanatjan Alibekov, a former researcher who was helped by the CIA to move to the United States. It is also possible that other countries or organizations have samples of the virus, either stolen or just not destroyed when they were supposed to be. (North Korea and Iraq are suspected to have these stockpiles.) Because of its extreme contagiousness, smallpox is considered a likely choice for bioterrorists if they were to have access to it. On the other hand, the technical difficulty of working with the virus and growing enough of it to use for large-scale operations without killing off those on their own side does reduce the likelihood of a bioterrorist attack with smallpox.

Whether the last two known archives of the virus should be destroyed has been argued for over a decade. Some feel that since the DNA sequence of the smallpox virus has been recorded and the vaccine is actually made from a related virus, not smallpox itself, that there's no reason to keep samples, and destroying the American and Russian repositories would reduce risk of the virus escaping in any way from them. Others feel that future research may need the actual virus (particularly for drugs to treat the disease), or that intentionally making an organism extinct is wrong even if it's a virulent disease.

Due to fears of bioterrorism, in 1997 the U.S. Department of Defense started to order a large amount of smallpox vaccine; two years later the Department of Health and Human Services followed suit. There are no plans to vaccinate most people in the U.S. because of the occasional serious reaction to the vaccination; however, in July 2002 U.S. plans to vaccinate health care and emergency workers were expanded from 15,000 to 500,000 people. The CDC is handling the logistics of this plan and the contingency plans for mass vaccinations in case of smallpox attacks. Vaccination within three or four days of being exposed to the virus usually prevents the disease from taking hold in a person. Not every virologist agrees that the "ring approach," used by WHO in their eradication of the natural disease and in the current U.S. plans, will work in modern society. The ring approach involves vaccinating all known contacts of every known smallpox case, preventing them from getting the disease and spreading farther; some argue that this worked in rural villages but will not in large cities with a mobile population. Hopefully it will never have to be tested.

Sources:
Broad, William J. "U.S. Plans Mass Smallpox Shots," The Tampa Tribune 7 July 2002.
Fenn, Elizabeth A. Pox Americana: The Great Smallpox Epidemic of 1775-1882. New York: Hill and Wang, 2001.
Tucker, Jonathan B. Scourge: The Once and Future Threat of Smallpox. New York: Atlantic Monthly Press, 2001.

Due to rising concerns about bioterrorism, the White House announced on December 12, 2002, that it planned to make the somewhat risky smallpox vaccine available to all Americans by 2004. The Bush Administration was concerned about releasing the smallpox vaccine to the public because hippies might get a hold of it and exploit it for recreational purposes; also, the vaccine is known to cause life-threatening side effects in certain individuals, and one or two people out of every million who are vaccinated can be expected to die from those side effects.

Beginning in January 2003, vaccination for smallpox will be mandatory for about 500,000 military personnel. The vaccine will be recommended for another 500,000 individuals who work in hospital emergency rooms or staff biohazard response teams. In early 2004, the White House estimates that the United States' enormous smallpox vaccine stockpile will be ready to be licensed and released to regular doctors, who can then distribute the vaccinations to any individual with twenty bucks and a thrill-seeker attitude.

The White House also made it clear that while it was releasing the smallpox vaccine to the public, it was not necessarily encouraging people to become vaccinated. The smallpox vaccine routinely produces more side effects than any other vaccine dispensed in the United States, making it an ideal choice for people hoping to get out of work on Friday, but not such a great idea for the citizenry as a whole.

The decision to run crazy through the streets, vaccinating everyone who has a forearm, screaming bloody murder about impending biological warfare and the destruction of society as we know it came on the heels of an announcement on Wednesday, December 11, 2002, when the Associated Press published a survey that found six in ten Americans were "worried" about smallpox and that two out of three people would opt to get vaccinated if given the opportunity.

The Associated Press pointed out, however, that the question about getting the smallpox vaccine was asked after several questions regarding threats of bioterror against the United States, so it's possible that "people being surveyed may have been thinking more about the threats than about the risks of the vaccine." The AP also admitted that people weren't adequately informed about the vaccine's risks (including the part about how you might die if you get it). So an informed reader might not take that "two out of three" figure totally to heart, because studies have consistently shown that a decent number of people tend to avoid things that are both unnecessary and have a tendency to kill them when left to their own devices.

Personally, I don't understand what the fuss is all about. When Saddam Hussein attacks us with his massive army of Giant Killer Robots (complete with US-manufactured Laser Rifles), we're all going to feel pretty darn silly for worrying about flu shots. Or anthrax vaccinations. Or whatever the hell this writeup was about...I forget. Anyway, if I were you, I'd invest your money in laser-proof armor and invisibility cloaks rather than some dumb injection. (But that's just one man's opinion.)

Small"pox` (?), n. [Small + pox, pocks.] Med.

A contagious, constitutional, febrile disease characterized by a peculiar eruption; variola. The cutaneous eruption is at first a collection of papules which become vesicles (first flat, subsequently umbilicated) and then pustules, and finally thick crusts which slough after a certain time, often leaving a pit, or scar.

© Webster 1913.