by David Isaacs
Smallpox sceptics
There were a number of valid reasons for concern about vaccination.
Two main approaches were initially used to produce the vaccine, both of which continued to be employed until the end of the 19th century. The cowpox was either grown on calf skin, from which material was scraped and injected directly into the arms of patients, or else fluid was taken from blisters on the arm of one vaccinated patient and injected into the next patient’s arm. Cow skin could carry infections, and when the vaccine was transferred from arm to arm, serious skin infections were common. The practice could also transmit other infections, including syphilis.
Some people were sceptical of the scientific basis of vaccination and had concerns about possible harms to health. Clergy often said it was against God’s natural order and unchristian to use material taken from animals.
The response of the British government was to enforce the uptake of the vaccine through legislation. In 1853, Parliament passed the Vaccination Act, introducing compulsory smallpox vaccination for infants up to three months old. In 1867 the Act was amended to extend the age requirement to 14 years and to introduce penalties for vaccine refusal.
The legislation was highly controversial. Compulsory vaccination met with vigorous resistance, with angry opponents arguing it infringed personal liberty. The vaccination was administered under the Poor Law, also responsible for the despised public workhouses portrayed by Charles Dickens in Oliver Twist. Consequently, British workers associated mandatory vaccination with other manifestations of class oppression. The laws precipitated the formation of large, vociferous anti-vaccination leagues.
Advocates of smallpox vaccination who tried to use reason to persuade dissenters were doomed to frustration. In 1877, the Reverend Charles Dodgson, better known under his pen name Lewis Carroll, replied to a letter in the Eastbourne Chronicle, in which a Mr Hume-Rothery claimed the smallpox vaccine was giving smallpox to large numbers of people. Carroll and Hume-Rothery engaged in an increasingly heated correspondence. Carroll, ‘a trifle ruffled but keeping to the point, retired after the third round’. Mr Hume-Rothery kept going until the editor gave up publishing his letters. Mr Hume-Rothery was unperturbed by being confronted with data or evidence that contradicted his cherished beliefs.
A major centre of English opposition was the Midlands industrial town of Leicester. The town’s population increased sharply from the turn of the 19th century as the Industrial Revolution took hold, and drainage facilities and housing proved inadequate. Leicester developed a reputation as a hotbed of typhus and other febrile illnesses, and had one of the highest death rates among English towns.
The Leicester (later the National) Anti-Vaccination League was founded in 1869 and soon put up candidates for election to the Board of Guardians, the body that administered the Vaccination Act. The anti-vaccination movement championed ‘the freedom for which the sons of Britain fought and bled long before our miserable local divisions rendered us a prey to the decaying laws of overbearing centralisation’.
The fates were unkind to those in Leicester who favoured immunisation. In 1872 the vaccination rate in Leicester children was over 90%. But this high rate unfortunately coincided with a local smallpox epidemic that saw 359 Leicester locals die in five years. The numbers convinced the Leicester public, wrongly, that vaccination caused smallpox. The Leicester movement grew from a handful of people to include most of the city.
The league began holding anti-vaccination rallies. At one of these, a local newspaper reported that:
An escort was formed, preceded by a banner, to escort a young mother and two men, all of whom had resolved to give themselves up to the police and undergo imprisonment in preference to having their children vaccinated. The three were attended by a numerous crowd . . . three hearty cheers were given for them, which were renewed with increased vigour as they entered the doors of the police cells.
In 1885, over 80,000 people marched through Leicester carrying banners, a child’s coffin and an effigy of Jenner. By 1889 there had been over 6000 prosecutions in Leicester, resulting in fines in over 3000 cases and imprisonment in 64. By 1892, only 3% of Leicester children were being immunised against smallpox despite the penalties for non-compliance.
Six years later, the British Government relented and introduced exemption certificates for parents who did not wish to vaccinate their children.
In the United States, mandatory vaccination was introduced in many States between 1843 and 1855. However, William Tebb, a leading British anti-vaccinationist, visited America to give lectures against vaccination. Following his visit the Anti-Vaccination Society of America was founded in 1879. The United States approach to dissent was characteristically litigious. In several States, including California, Illinois and Wisconsin, Anti-Vaccination Society members applied to the courts to have vaccination laws repealed, without success.
In 1902, when smallpox broke out in Cambridge, Massachusetts, the local board of health mandated that all city residents be vaccinated against smallpox. One resident, Henning Jacobson, refused, arguing that the law violated his right to care for his own body. The city successfully filed criminal charges against him. Jacobson appealed to the United States Supreme Court, which in 1905 ruled that, in the event of a communicable disease, the State was legally entitled to enact compulsory laws to protect the public.
It was the first United States Supreme Court ruling ever on the power of States in relation to public health. It is surely relevant to current debates about coercion versus respect for parental autonomy.
By the early 20th century new practices were making vaccination safer. To reduce the risk of contamination, arm-to-arm transfer was banned, and vaccines were made from cowpox grown in cell cultures or in hens’ eggs rather than live animals.
As the efficacy of smallpox vaccination became increasingly evident and smallpox disappeared, organised opposition to immunisation receded. The membership of anti-vaccination leagues plummeted and the leagues folded.
Smallpox eradication
Smallpox had disappeared from several Northern European countries by 1900. However, it persisted at low levels in many other wealthy countries and the incidence remained extremely high in resource-poor countries.
The first concerted effort to set up a widespread smallpox eradication program was made by the Pan American Health Organization (PAHO) in 1950. PAHO’s campaign successfully eliminated smallpox from the whole of the Americas except Argentina, Brazil, Colombia and Ecuador. Despite this success, in 1958 an estimated 2 million people globally still died from the disease every year, mostly in Africa and the Indian subcontinent.
The World Health Organization (WHO) was established in 1948, and one of its earliest initiatives was to try to control smallpox. The first WHO smallpox campaign started in 1958, but had little effect due to insufficient funds. However, in 1967, the WHO introduced a new Intensified Smallpox Eradication Programme, with the ambitious aim of eliminating the disease entirely.
The team in charge of the program was known as the Smallpox Eradication Unit (SEU), based in Geneva and consisting of 812 staff from 73 countries. The overall leader was 38-year-old American Donald Ainslie Henderson (1928–2016), known all his life as ‘DA’. DA was a tall, imposing man, with a stentorian voice that commanded attention. He believed in what he called a ‘shoe-leather approach’: actually going to the place where an epidemic was occurring, as opposed to staying put in the office. (To his wife’s dismay, DA used to bring home scabs from suspected African and Asian smallpox victims and store the scabs in their fridge until he could get them tested.)
This was before computers, before mobile phones, even before fax machines. DA insisted on a 48-hour rule: the staff in the office – never more than 10 at a time – had to answer all queries, written or telephonic, within two days. Knowing the importance of feedback, DA published regular reports, an impressive 230 in all, on his team’s progress.
The SEU’s ambitious goal depended heavily on a
dequate funds, adequate vaccine supply, and a new method of surveillance to identify smallpox cases, developed by a Czech epidemiologist, Karel Raška. Initially the vaccine was provided mainly by the Soviet Union and the United States, but in the later stages of the program, over 80% of it was produced in countries where the vaccine was needed. The ability to make safe vaccines in resource-poor countries has been an important factor in the success of some later immunisation programs.
A critical advance in smallpox eradication came through a United States doctor named Bill Foege. As a teenager, Bill injured his hip and had to wear an orthopaedic body cast. Always fascinated by his uncle, a missionary in Papua New Guinea, Bill read about Albert Schweitzer’s work in Africa and swore he would travel there as a doctor. It was while working on smallpox in Eastern Nigeria in 1966 that he discovered his team could stop smallpox from spreading by immunising only people who had been exposed to an infected person. Foege’s technique of ‘ring vaccination’ meant that the whole population did not have to be vaccinated, saving precious resources of time and money. When one or more people in a village or town were diagnosed with smallpox, all those who might have been exposed to infection were identified and vaccinated. This was the first ‘ring’. Then, a second ring of people who had possibly been exposed to the first ring was identified and vaccinated. Smallpox was thus surrounded and prevented from spreading, just as fire fighters scorch surrounding land to isolate a fire. This was an artificial form of herd immunity (see Chapter 1), and it worked a treat.
Smallpox may be an ancient disease, and one that mainly affected people in poor countries, but there are smallpox survivors alive today in Western countries who can bear witness to its ravages. In 1962, a traveller from Pakistan named Shuka Mia arrived in Cardiff, Wales. He was diagnosed with smallpox and put in isolation, and survived. A mass immunisation program was mounted throughout Wales amid fears the smallpox might spread, and 900,000 people were vaccinated.
The Rhondda Valley is some way from Cardiff, and how the disease spread there several weeks later is unknown. It also unaccountably reached nearby Bridgend. The first person to fall ill in the Rhondda Valley was 23-year-old Margaret Mansfield, who was heavily pregnant when she developed smallpox. She was admitted to the East Glamorgan Hospital, where her baby was stillborn. The family’s tragedy was far from over. Margaret died soon afterwards from smallpox, and within days so did her 24-year-old sister, Patricia Pugh. Only one doctor in East Glamorgan Hospital had declined to be immunised during the mass immunisation program. He treated Margaret Mansfield, caught smallpox from her and died too.
Margaret’s neighbour, 22-year-old Marion Jones, caught smallpox from Margaret, but survived. In 2002, as a 62-year-old grandmother, Marion was interviewed on BBC Television. She tried to describe the severity of her symptoms, although she had been so ill that her memory of them was hazy. What she could say was that her scars took months to heal and all her hair fell out. She also explained the devastating effect of the outbreak on the whole community. Her husband, parents and her four brothers and sisters had all caught smallpox, and all eight of them had spent over three months in hospital.
In all, 19 people died during the 1962 South Wales outbreak, most of them healthy young women.
Smallpox was eradicated from Europe by 1972, but continued to kill and scar people on the Indian subcontinent. As the disease disappeared, people there were offered a payment if they notified (reported) a case that was verified as smallpox.
The last person naturally infected with the more virulent strain of smallpox, variola major, was three-year-old Rahima Banu from Bangladesh. In October 1975, Rahima was notified by a fellow villager, an eight-year-old girl called Bilkisunnessa, to local health authorities, who paid Bilkisunnessa for the notification.
The Bangladeshi health authorities sent a telegram to DA Henderson in America. DA sent a WHO team to the village. They confirmed the diagnosis and treated Rahima, who survived. When she was 18 years old, Rahima married a farmer and they had four children. Her fame allowed her to make money posing for photographs. Despite her fame, Rahima reported that she was stigmatised by many people, including her husband’s family.
By the end of 1975, the only remaining smallpox cases, of the variola minor strain, were in the Horn of Africa, where civil war, famine and transport problems made conditions particularly difficult. An intensive program of surveillance, containment and vaccination was instituted in 1977, under the supervision of an Australian scientist, Frank Fenner (1914–2010).
The last naturally occurring case of variola minor was diagnosed in Ali Maow Maalin, a hospital cook in Somalia, on 26 October 1977. He not only made a full recovery, but also became a polio vaccinator himself. Tragically, he died in 2013, aged just 59, from malaria, which he contracted in Somalia while delivering polio vaccine.
The smallpox story was not quite over, however. In 1978 two people contracted smallpox when the virus was accidentally released from a laboratory at the University of Birmingham in England. One of them was 40-year-old medical photographer Janet Parker. Her workplace was located on the floor above the laboratory, and an inquiry found that the virus had probably spread to her darkroom from the laboratory through ducting. When Janet fell desperately ill, her parents were quarantined because they had been in contact with her. They did not catch smallpox, but while in quarantine her father had a cardiac arrest and died suddenly. The next day, Professor Henry Bedson, the scientist responsible for smallpox research at the university, went into his garden shed when his wife was distracted and killed himself by cutting his own throat. He left a suicide note: ‘I am so sorry to have misplaced the trust which so many of my friends and colleagues have placed in me and my work.’
Six days after her father died, Janet Parker succumbed to smallpox. The disease had claimed its last victim.
Very few people had believed smallpox could ever be eliminated, but DA Henderson and his team had rid the world of one of its most lethal viruses within a mere 10 years. The WHO was used to a more leisurely approach to health programs, and did not know what had hit it. What had hit it was DA.
DA Henderson was one of the heroes of smallpox eradication. He played a vital role in eradicating a disease that is estimated to have killed 300 million people in the 20th century alone – an achievement of which he was deservedly immensely proud.
Another major player in smallpox eradication was Frank Fenner, a great Australian virologist who chaired the WHO Global Commission for the Certification of Smallpox Eradication, which visited and researched the evidence for smallpox eradication from all endemic (affected) countries. Frank was a modest and charming man, and would always talk to and encourage students. He was small and fastidious and always meticulously dressed. He was nothing if not comprehensive. One of his lectures went on so long he had to be carried off the podium by two men, each lifting one elbow. Frank continued giving his lecture as he left the stage. His account of the history of the eradication of smallpox commissioned by the WHO ran to over 1400 pages (something I can verify, having printed the whole document by mistake while researching this book – much to the amusement of my work colleagues).
One of Frank’s greatest moments was when he was given the honour of announcing the eradication of smallpox to the World Health Assembly in 1980.
The massive global effort made to eradicate smallpox and the immensity of the achievement can hardly be over-emphasised. It is estimated that the annual cost of the smallpox campaign from 1967 to 1979 was US$23 million, and that the world saves over US$1 billion every year by no longer having to vaccinate.
But that is just the money. The saving in human suffering is immeasurable.
The eradication of smallpox is the story of Edward Jenner’s careful scientific observation and his experimentation on little James Phipps, of passionate supporters like Lady Mary Montagu and equally passionate opponents, of determined and dedicated doctors like DA Henderson and Frank Fenner, of tragedies like the deaths of Janet Parker and Henry
Bedson. Remarkably, thanks to immunisation, children like Rahima Banu and young adults like Ali Maow Maalin, Marion Jones and Margaret Mansfield will never again be at risk from the scourge that once was smallpox.
CHAPTER 3
The flawed genius of Louis Pasteur
On 18 October 1831, eight-year-old Louis Pasteur was terrified to hear screams coming from the outskirts of his village of Arbois, in the mountainous Jura region of eastern France. A vicious wolf had attacked the village and several villagers had suffered serious bites. If they developed rabies, they were certain to suffer a slow, terrible death that would involve frothing at the mouth and severe agitation, followed by delirium and convulsions. There was no known cure. For thousands of years those who developed rabies had died slowly and horribly, their relatives forced to sit by in helpless anguish.
Louis watched with horror as the wolf’s victims, who included one of his closest friends, were taken to the blacksmith’s and held down while the blacksmith cauterised their wounds. This barbaric treatment would later be shown to be totally ineffective, but it had a profound effect on Louis Pasteur. As he heard the awful screams of his neighbours when the red-hot branding iron burned their skin, and as the acrid smell of burning human flesh reached his nostrils, Louis vowed to himself he would find a way of preventing rabies.
He would honour that vow, and become one of the most important figures in the history of vaccination. Yet Louis Pasteur was a man of paradoxes and contradictions. From a humble background in rural France, he rose to become one of the greatest scientists of the 19th century, and indeed of all time. His contribution to vaccine development was invaluable, but he was not a doctor. He played a huge role in antisepsis, leading to the later development of antibiotics, but he was not a microbiologist. He was in fact a chemist, whose pioneering work on micro-organisms and vaccines reverberated through the fields of biology and medicine, and remains highly relevant to this day.