The Coming Plague

by Laurie Garrett

  II

  Imbued with profound optimism, coupled with the post-World War II American “can do” attitude, the world’s public health community mounted two ambitious campaigns to eradicate microbes from the planet. One effort would succeed, becoming the greatest triumph of modern public health. The other would fail so miserably that the targeted microbes would increase both in numbers and in virulence, and the Homo sapiens death toll would soar.

  Humanity’s great success story would be smallpox.

  In 1958 the Soviet Union went before the World Health Assembly—the legislative body of the World Health Organization in Geneva—to request an international campaign for the elimination of smallpox, winning virtually universal support.

  Historically, smallpox had proven a particularly vicious killer. It did not, as was typical for most infectious diseases, preferentially attack the most impoverished members of society.19 In A.D. 165, the Roman Empire was devastated by an epidemic now believed to have been smallpox. The pestilence raged for fifteen years, claiming victims in all social strata in such high numbers that some parts of the Roman Empire lost 25 to 35 percent of their people.20 It is believed that the virus struck a completely nonimmune population, having first appeared in Asia some one hundred years earlier.21

  Over subsequent centuries equally devastating pandemics of the viral disease claimed millions of lives in China, Japan, the Roman Empire, Europe, and the Americas.22 According to historian William McNeill, Cortez’s capture of Mexico City with just a small army of exhausted Spanish irregulars under his command was possible only because the Europeans had unknowingly spread smallpox throughout the land. When Cortez launched his final assault on the capital, few Aztec soldiers were alive and well. Smallpox, together with measles, tuberculosis, and influenza, claimed an estimated 56 million Amerindian lives during the initial years of the Spanish conquest.23

  By 1958, when the Soviets called for global eradication, smallpox was killing 2 million people a year, and cases could be found in thirty-three countries.

  The virus could be spread by touch or respiration, and scientists carefully calculated the infectious dose necessary to produce disease—the numbers of viruses present in a tiny droplet of human exhalant and other details of transmission. It turned out that a single milliliter droplet of human lung exhalant contained 1,000 more viruses than were necessary to produce infection in the unfortunate soul who inhaled that minuscule bit of moisture.24

  Both the historic devastation and the widespread rates of contemporary infection seemed to argue for skepticism about smallpox eradication.

  On the other hand, several aspects of the biology of smallpox gave cause for optimism. Foremost was the existence of an extremely effective vaccine that, in various forms, had been in use since 1796.25 In modern times the cowpox vaccine, made from the bovine form of the virus, had been perfected, making it over 99 percent effective, with virtually no side effects. Smallpox was also easy to diagnose, and cases of the disease could readily be spotted by people with no professional training. During severe illness, grotesque bulbous inflammations formed on the individual’s face and skin. The distinct poxing, once healed, left visible scars anybody could recognize.

  Because the virus was spread directly from person to person there were no troublesome vectors to control, such as mosquitoes, rats, ticks, or fleas. And the very thing that made smallpox so terrifying—its rapid lethality—also rendered it controllable because the viruses multiplied and spread so quickly that most people were infectious for only four or five days and their debilitation was so great that they could not walk about and infect large numbers of people.

  Though eradication would require over 250 million vaccine doses per year and a worldwide effort to reach all citizens at risk for smallpox—even those in the midst of wars, social tyranny, famine, or disaster—the program began amid optimism in 1967 under the leadership of American physician Donald “D. A.” Henderson.26

  Nations of the Northern Hemisphere and Latin America were already well on their way to smallpox eradication in 1967, but the disease was firmly in place in many parts of Africa and Asia, where religion often proved a major barrier to vaccination.

  Before the campaign began, researchers scoured pilot project areas to see how accurately smallpox cases were reported. Their conclusion was that an astonishing 95 percent of all cases of the disease were never reported to national or international public health authorities. The reasons for such dramatic underreporting were numerous: local authorities feared being penalized if higher-ups learned that epidemics had occurred in their jurisdictions; in some areas the disease was simply accepted as a fact of life; outbreaks tended to occur in confined areas and could easily be missed by quick national surveys; during centuries of colonialism, people’s homes were often burned if smallpox was found in a family member, so people in former colonies naturally concluded it was best not to inform authorities.27

  Ultimately, Henderson’s team at WHO devised a smallpox plan of attack that boldly confronted these issues by dispersing dozens of skilled tropical disease experts all over the world in search of small outbreaks of the virus. Once such an outbreak was identified, local government was mobilized and residents of the area were vaccinated. Inoculation was occasionally carried out forcibly; in some instances people’s homes were invaded and local police assisted the inoculators.

  Because both superpowers wholeheartedly supported the campaign, few governments resisted public health efforts that often took on military overtones. The WHO teams braved civil wars, floods, religious battles, and a variety of geographic and logistic problems to accomplish their task in eleven years.

  In Bangladesh, for example, where the worldwide campaign faced its toughest battle due to the great population density and ancient smallpox endemicity, French physician Daniel Tarantola braved confrontation with an infamous murderer thought to be a smallpox carrier. Without police protection, Tarantola approached the murderer and his outlaw gang in their hideout and faced down guns to immunize them. The word from villagers was that members of the gang had classic pockmarks on their faces and the robbers were spreading the epidemic throughout the countryside. The village intelligence proved accurate, and the immunizations prevented a local epidemic. The gang leader, however, died of smallpox two days after Tarantola’s courageous confrontation.

  During the late 1960s, Tarantola, then a Paris medical student, volunteered his services to Médecins Sans Frontieres, an idealistic organization that sent European medical volunteers into war-torn areas to provide care to civilian populations. In the midst of civil war, the twenty-something Tarantola ran a pediatric ward in Biafra. Two years later, with some course work yet to be completed at the University of Paris Medical School, Tarantola signed on for a two-year stint in Africa in a small hospital in newly decolonized Burkina Faso.

  Tarantola was a product of his times. While he studied the intricate workings of human kidneys, riots raged in the streets of Paris. Students formed alliances with factory workers and, inspired by such heroes of the day as Mao Zedong, Che Guevara, Ho Chi Minh, Herbert Marcuse, and Kwame Nkrumah, challenged the very existence of the De Gaulle government. Such bold, youthful actions were reflected all over the world, from Washington to Jakarta, as college-age young adults challenged the established order of things. A mood of activism and boldness infected the usually staid halls of medical schools internationally, inspiring would-be physicians like Tarantola to dream of a world in which villagers in Burkina Faso had as much a right to expect an eighty-year life span as did les parisiennes bourgeois.

  When young doctors like Tarantola looked around the world for inspiration in the 1960s, they saw people nearly their own age leading revolutions against the old European colonial powers, taking control of governments and debating the creation of new types of social orders. Like many European and American idealists, Tarantola thought that with enough energy and West
ern money, just about anything was possible “if there is political will.”

  It was with that zeal that he approached his work in the Fada N’Gourma Rural Hospital in Burkina Faso, developing a grass-roots primary health care system that radically reduced infectious disease problems in the area. For his efforts, Tarantola was given the 1973 Albert Schweitzer Award.

  The ink was barely dry on his medical degree when Tarantola next signed on with another French charitable group, Brothers to All Men, to do primary health care in northern Bangladesh. Because he had no command of English, the second language of Bangladesh, Tarantola promptly taught himself Bengali.

  He had been in the country only six months when he was recruited to work with the smallpox campaign. Like Tarantola, most of the smallpox investigators were young (under thirty-five), Caucasian, idealistic males from Europe and North America. At the time, this cultural and gender homogeneity made some team members uncomfortable, but the grander goal of eliminating one of the planet’s most notorious scourges outweighed concerns about neocolonialistic appearances.

  In 1972 Don Francis had just barely completed his pediatrics residency at Los Angeles County Hospital and signed on with the CDC when smallpox broke out in Kosovo, Yugoslavia. The young doctor was just setting up a CDC disease surveillance office in Oregon when Atlanta called, ordering him to go to Belgrade. Francis raced home, grabbed a few changes of clothing, a shaving kit, and his passport, and headed for the airport. Seven hours later he was in Washington, D.C., getting a briefing and cases of vaccination equipment. Before midnight he was asleep on a jet flying somewhere over the Atlantic, and in the morning he hit the ground running in Belgrade.

  A few weeks later, the Yugoslavian outbreak safely contained, Francis was in Khartoum, the capital of Sudan, hunting down smallpox cases. From there, he went on to India and Bangladesh.

  By the time Francis’s obligations to the smallpox campaign were fulfilled, nearly three years had elapsed since he answered that phone call one morning in Oregon.

  Another young American physician, David Heymann, saw a one-shot CDC assignment turn into two years of Indian smallpox hunting in Bihar and Calcutta. When Heymann’s group vaccinated somebody, they always showed pictures of smallpox-stricken Indians and asked for names of people suffering from the disease. In some areas they offered rewards to people who could steer the team to active smallpox cases. If they found a case, the ailing person was quarantined and everybody in the region vaccinated—some against their will.

  Despite the coercive nature of their activities, few of the fieldworkers doubted that, in the greater scheme of things, what they were doing was just: if 2 million people a year could survive because of momentary inconveniences visited upon a few, then how could there be any doubt about the righteousness of their campaign?

  The one concern that did constantly haunt D. A. Henderson and his team was the cost of failure. In those brief moments when they allowed themselves to entertain the notion that smallpox might not be eradicated, the scientists knew the world might never again be willing to mobilize across political, national, cultural, racial, and religious boundaries to share a common battle against disease. The stakes, clearly, were high.

  By the summer of 1974, the WHO team was about to declare victory in Bangladesh, the last stubborn holdout of the virulent variola major form of smallpox. Officials had even gone so far as to publicly predict that complete elimination of the virus would occur before that November.

  But then the rains came, and came, and came. By August, Bangladesh was besieged by water, as dikes and dams burst under the monsoon’s force. Refugees poured by the tens of thousands into Dhaka. Famine spread throughout the land, and the country seemed to be coming apart at the seams. Shortly before the floods, the Prime Minister, Sheik Mujibur Rahman, was assassinated, and a series of riots, civil violence, and coups followed, lasting well into 1975.

  After being so close to victory, the task of eliminating—indeed, amid the chaos, finding—the remaining cases seemed so daunting that most of the eradication staff gave up. They were exhausted, burnt out.

  But Tarantola told his staff, “Look, this just means we have to get down to micromanagement. We must look at the trees now, not the forest. Take it day by day.”

  Slowly staff confidence and morale were rebuilt, smallpox cases were found, and the enthusiasm returned. Within a year, victory once again seemed within grasp. Heymann and Francis were reporting total success in India, and no new outbreaks had occurred in Africa in months. With all eyes on Bangladesh, excitement rose.

  One of the last infected villages was outside the city of Chittagong, which was under the command of an Army general. Not knowing what side of the civil war that general was on, or how he felt about foreigners, Tarantola confronted the general and requested permission to vaccinate the villagers. Permission was initially denied, and the disease spread. Once again, it seemed the gigantic obstacles of Bangladesh would force the WHO team to snatch defeat from the jaws of victory.

  But the general finally relented, the last outbreak was stifled, and champagne was poured in Dhaka. Tarantola greedily guzzled the champagne, exultant after years of round-the-clock viral pursuit.

  The next morning victory once again disappeared when word came that smallpox had surfaced on Bhola, an island off Bangladesh. For the third time the team was forced to remobilize after having been convinced the war was over. This time, when all the affected islanders had been vaccinated, Henderson held his breath a bit before announcing success.

  On November 1975, D. A. Henderson was able to announce to the world that a three-year-old Bangladeshi girl named Rahima Banu had been cured, and represented the last case of wild variola major in human history. Two years later, on October 26, 1977, the last case of the less virulent variola minor would be found in Merka, Somalia.

  By then Dr. Isao Arita had been in charge of the international effort for ten months, Henderson having retired. The Japanese physician ran the program with at least as much energy as the tall, bombastic American, but with a personal style that was more low-key and witty. In times of tension, Arita told jokes.

  His humor was put to the test in the Horn of Africa in early 1977, just weeks after military leader Mengistu Haile Mariam seized power in Ethiopia, installing a Soviet-backed, communist government. The military government in Somalia laid claim to Ogaden, a region then part of eastern Ethiopia, and full-scale war was underway. Ethiopia, backed by Soviet arms and Cuban troops, mounted a powerful defense of Ogaden. But Somalia, despite its left-wing leanings, successfully obtained Cold War countersupport from the United States. As war raged, more than a million civilian refugees fled the area, pouring into nearby Somali and Ethiopian rural provinces that were in the throes of their second and third years of drought and starvation.

  It was in that area—Ogaden—that the world’s last known cases of smallpox variola minor could be found, primarily among Somali Muslims.

  Arita knew that UN flags and WHO credentials would offer little protection to his scientific team members in such a volatile situation, yet he also felt time was running out. It was February 1977, and the Hajj was just ten months away. During the Hajj thousands of devout Somali Muslims would make their pilgrimage to Mecca, where they would eat, sleep, and pray for several days with some 2 million other followers of Islam from all over the world. If infected pilgrims were part of the hajj, all efforts to eradicate smallpox would end in failure.

  For months the multinational team struggled against the elements, avoided the war’s front, and tracked down smallpox cases among the refugees and villagers of Ogaden. By October the numbers of rumored cases seemed small, and despite the onset of the rainy season, Arita ordered the team to push on. Half the team got mired in mud floes during those rainy days, and one American scientist, Joe McCormick, spent three days alone in Ogaden, stranded in a Land-Rover stuck in a three-foot-deep wall of mud.

  Finall
y, in Merka, Somalia, the team found the world’s last case of variola minor.

  All Maow Maalin would be cured, and all forms of smallpox disappeared. Smallpox had been conquered.28

  Their jobs completed, smallpox team members dispersed to public health jobs all over the world. Surprisingly, they were not eagerly snatched up by WHO, or congratulated individually for their magnificent efforts. On the contrary, the brash young smallpox scientists were considered arrogant and thoughtless. They violated too many WHO bureaucratic guidelines. And they operated with a single goal in mind—a perspective quite unlike that of those who usually drove the vaguely pro-health WHO and national ministries of health worldwide.

  “Science really suffers from bureaucracy,” Arita would later declare, adding, “If we hadn’t broken every single WHO rule many times over, we would never have defeated smallpox. Never.”

  Even Arita and Henderson, the heroic leaders of the smallpox eradication effort, were criticized for crossing too many WHO lines. Arita shrugged it off and returned to his hometown, Kumamoto, to run Japan’s National Hospital.

  After a period of being the target of animosity in the Geneva headquarters of WHO, Tarantola was thrilled to be assigned to an overseas job, running childhood vaccination campaigns in Indonesia. Francis was burned out, so he followed his girlfriend to Harvard, where he planned to do virology research. Heymann moved to Atlanta, signing on with the CDC. All three men would work together again, over a decade later, to combat another global epidemic.

  Eradication took eleven years, involving about a hundred highly trained professionals and thousands of local health workers and staff worldwide. It was achieved at a cost of $300 million.29

  On May 8, 1980, the World Health Assembly formally declared that “the World and all its peoples have won freedom from smallpox, which was a most devastating disease sweeping in epidemic form through many countries since earliest times, leaving death, blindness, and disfigurement in its wake and which only a decade ago was rampant in Africa, Asia, and South America.”30