Smallpox, Syphilis and Salvation

by Sheryl Persson

  In August 1803, Edward Jenner was granted the freedom of the City of London, (an historical and ceremonial honour bestowed on citizens considered worthy of veneration) and a month later the Royal Humane Society made him an honorary member. At the age of 54 the discoverer of vaccination had become a celebrity but over the next few years as Jenner’s fame grew abroad, so did his tribulations at home. In London in 1803, having been given royal approval, the Royal Jennerian Institute was founded with Jenner as its president. The mission of the institute, the vaccination of the poor, accorded with Jenner’s philosophy of medicine. In Berkeley, Jenner and Catherine had built a clinic adjacent to their cottage so that they could give free vaccinations. Eager for a chance at salvation, people queued in their hundreds and the clinic soon became known as the ‘Temple of Vaccinia’.[35]

  But there was a cost to Jenner’s generosity. When Jenner’s coffers began to run low again he made a fundamental error in asking a friend, Dr Walker, to take over the responsibility of inoculating the poor. Walker, who had a reputation for arrogance, compromised the success of the institute by obtaining the vaccine from patients’ lesions. After Walker was dismissed he set up a rival institution, which eventually failed, but in the interim the Royal Jennerian Institute was shut and Jenner came perilously close to being imprisoned for debt.

  Old friends rallied again and another grant was requested from parliament. This time the process was stymied by petty professional jealousy between the Royal College of Physicians and the College of Surgeons. The former was asked by parliament to establish a vaccination commission to investigate the request, and the latter was not included and felt snubbed. So widespread was Jenner’s reputation, however, that while the medical profession bickered, donations suddenly flooded in from Calcutta in India where Jenner was held in high esteem.[36] Jenner had been supplying cowpox material to the world, made possible by a technique he had developed. Cowpox matter was dried onto threads or glass making it easily transportable from one continent to another while retaining its efficacy in transit. Jenner was not only generous with his money. He gave his time and his advice freely to anyone who would benefit.

  In the same way that smallpox had travelled around the globe the vaccine went in pursuit. During the period 1803 to 1806, King Charles IV of Spain had Jenner’s vaccine transported to Spanish colonies in North and South America and Asia but the motive for this mass vaccination was not altruistic. The governor of the Council of the Indies had suggested that the economic benefits from vaccination would outweigh the costs because smallpox took such a huge toll and thus diminished tax revenues for Spain.[37] The method employed to transport the vaccine may not have met with Jenner’s approval. On the ship sailing to the Spanish colonies were 22 orphan children who were sequentially inoculated arm-to-arm thus ensuring the viability of the vaccine.

  Napoleon Bonaparte was also a believer and in 1805 all his troops who had not had smallpox were vaccinated with the ‘Jennerian vaccine’. One year later he ordered that French civilians also be vaccinated. The vital importance of the vaccine was acknowledged in 1807 in the Grand Duchy of Hesse when the first smallpox vaccination law was passed. Bavaria and Denmark followed suit. Smallpox vaccine became the first mandatory vaccine in the United States in 1809 when Massachusetts required the entire state population to be vaccinated against the disease.[38] Only a decade after the introduction of the vaccine it was being widely used throughout Europe and the Americas and had been taken up in the Middle East, India, China and Australia.

  With the success of the vaccine Edward Jenner had become so influential that the Emperor of Austria and the King of Spain freed English prisoners of war after Jenner personally mediated on their behalf. In 1813 when Napoleon was asked to release a captain in the English army who was a relative of Jenner’s, Napoleon exclaimed, ‘I cannot refuse Jenner anything! He has been my most faithful servant in the European campaigns.’[39]

  Despite this stellar fame, Jenner’s financial tribulations continued. In 1807 the British parliament finally granted him £20,000 and two years later in 1809, because the Royal Jennerian Institute had failed, they set up the National Vaccine Establishment with Jenner as director. But the carping and destructive opposition, the negative articles and professional jealousy that Jenner had endured since he first published Inquiry had not abated. There were members on the board of directors of the National Vaccine Establishment who had contrary views to Jenner, who was now 60 years old. The struggle had been long and hard. Enough was enough. Jenner resigned before the first official board meeting. The man who had come to refer to himself as the ‘Vaccine Clerk to the World’ retired from public life and until 1822 continued to practise as a country doctor.[40]

  Edward Jenner’s later years were marked by new difficulties. In 1813 when the University of Oxford awarded him an honorary medical degree, Jenner cantankerously refused to wear a cap and gown. This was interpreted as a symptom of his increasing age and his diminishing intellectual ability. The many battles he had fought had taken their toll. Even though he had triumphed over ‘the most terrible of the ministers of death’, Jenner’s own life had not been immune from the tragedy of disease. His son Edward had died of tuberculosis when he was a young man, and perhaps when he needed her most Jenner also lost Catherine. Through much of their married life she had been plagued by poor health and in 1815 Catherine died from the same disease that had taken her son.

  After Catherine’s death Jenner was lonely and suffered increasing depression. He had little contact with his remaining son and daughter. He experienced a recurrence of a problem he had suffered in childhood, variously described as auditory hallucinations and neurological seizures. Whatever the nature of his mental disorder, Jenner was suffering and he became paranoid and withdrawn.[41] It was only when he began to pursue some of his old hobbies such as collecting fossils and gardening that his health improved somewhat, but his mind was no longer as incisive as it had once been. Medical articles that Edward Jenner wrote during this period were dismissed as second rate. However, in 1820, at the age of 71, Jenner, still fascinated by natural science, submitted an article to the Royal Society about the migration of birds. Deemed an exceptional piece of work, it was published in Philosophical Transactions after his death.[42]

  In 1820 Jenner suffered a mild stroke but to the end, despite his tribulations, he was still a kind and gentle man. On the day before his death in the winter of 1823, Jenner walked to a neigbouring village to ensure that a number of poor families there were provided with fuel to keep them warm. On 25 January Jenner was found unconscious on the floor of his library. He had suffered another stroke which paralysed his right side and early the next morning Edward Jenner, the man who had liberated so many from the scourge of smallpox, died very much alone at the age of 73. He had received the freedom of many cities and honorary degrees and memberships from societies and universities worldwide; Napoleon had minted a medal in his honour; he had received a ring from the Empress of Russia and a belt of Wampum beads from the North American Indian chiefs. But, sadly, very few people came to farewell an old man at his funeral. Edward Jenner was buried near the altar in Berkeley church.

  Edward Jenner did not receive a knighthood. The principal monument to commemorate his extraordinary contribution is a statue in Kensington Gardens in London inscribed simply with the name ‘Jenner’. Other statues of this incomparable benefactor have since been erected in many countries, monuments that honour his legacy to humanity. A century after the introduction of the first vaccine, Louis Pasteur paid tribute to Jenner in an address to the International Medical Congress in London in 1891. In his speech Pasteur extended the term ‘vaccination’ to other agents that had been developed to protect against disease, ‘as a homage to the merit of and to the immense services rendered by one of the greatest of Englishmen’.[43]

  ***

  What Jenner achieved was indeed monumental. He was the first person to use science to produce a method of controlling an endemic infectious dise
ase on a large scale. Although some argue he did not discover vaccination, Jenner made it viable and laid the foundations for many of medicine’s greatest triumphs. His scientific genius enabled him through experimentation to demonstrate that a folk medicine tradition could be scientifically tested and verified. Jenner’s methodology of injecting dead bacteria or their toxins, as well as dead or weakened viruses, into the human body to develop resistance to dreaded lethal diseases has since been used to fight diseases such as bubonic plague, rabies, anthrax, chickenpox, cholera, diphtheria, German measles, mumps, paratyphoid fever, pneumococcal pneumonia, poliomyelitis, tetanus, typhoid fever, typhus, whooping cough and yellow fever.[44]

  Vital to the eventual eradication of smallpox was Jenner’s perseverance despite the vehement opposition to his ideas. Jenner’s pamphlet on cowpox vaccination, The Origin of the Vaccinae Inoculation, issued in 1801, ended with the prophetic words, ‘the annihilation of the Small Pox, the most dreadful scourge of the human species, must be the final result of this practice’.[45] But it was to be almost 200 years after the vaccination of James Phipps that this prediction would be fulfilled.

  As vaccination spread the dangerous practice of variolation fell out of favour and was forbidden by an Act of Parliament in Britain in 1840. In Europe, the cowpox vaccine was prepared in large quantities by growing the virus on calfskin and more and more countries introduced compulsory vaccination. Britain followed Europe in 1853. It did not take long for opposition to compulsory vaccination to arise. Anti-vaccinationists and civil libertarians organised protest marches and demanded freedom of choice. The vaccination debate that began in the 1800s continues today.

  At the turn of the twentieth century, despite the proven effectiveness of Jenner’s vaccine, smallpox remained a dangerous disease worldwide. Other methods of treatment and protection were tried. Especially popular, but somewhat arcane, was the use of red objects and light, a therapy that dated back to tenth-century Japan. The uptake of the vaccine was hampered initially because it was in short supply and hard to store, especially in hot climates. In 1926 the League of Nations’ Smallpox and Vaccination Commission began to study the production, testing, standardisation, storage and delivery of the smallpox vaccine, while individual nations conducted their own research. During the 1920s French and Dutch researchers developed a dried vaccine for use in their colonies in the tropics.[46] It was hardier, but the quality was inconsistent.

  In the United States, the more virulent form of smallpox, variola major, continued to be widespread throughout the nineteenth century before being controlled. An unexpected outbreak in New York City in 1947 led to the development of a new method of freeze-drying the vaccine in ampoules. The great advantage of this was that the vaccine could last for months without refrigeration, even in tropical climates. Consequently, after 1949 there were no endemic cases of smallpox in the United States and the increasing availability of this highly effective and more stable vaccine afforded new opportunities for the successful eradication of smallpox worldwide, which is what Jenner had conceived of and believed possible.

  A coordinated campaign for global eradication was needed. In 1948 when smallpox was still a threat in at least 90 countries, the World Health Organization (WHO) took over the health functions of the League of Nations and in 1950 launched the first large-scale smallpox eradication effort with the goal of eliminating smallpox in the Americas. The Soviet Union proposed a global campaign in 1958 but although some countries established smallpox eradication programs, there was no coordinated infrastructure and many of the programs faltered due to insufficient vaccine supplies and limited resources.

  It was one step forward and two steps back. The WHO proposed the cessation of routine smallpox vaccination, which seemed contrary to the ideal of eradicating smallpox. There was an economic motive, the cost of the vaccine, but there were also complications associated with it. The calf-lymph vaccine was highly protective but could cause severe reactions, sometimes resulting in death. In the last natural smallpox outbreak in Britain, where outbreaks of smallpox continued up to the 1960s, the virus often carried by travellers from countries where it was still endemic, many more people died from vaccine reactions than from smallpox infection itself. Compulsory vaccination ended in Britain in 1971.[47] Following this a more attenuated, or weaker, vaccine was developed in order to minimise the risks and production of the calf-lymph vaccine was suspended in 1982.

  It was in 1966 that the nineteenth World Health Assembly (WHA) finally adopted a resolution sponsored by several countries, including the United States and the Soviet Union, which set the specific goal of wiping out smallpox within ten years. After extensive debate, the WHA approved US$2.4 million for the global effort, but many countries thought it was an impossible and unrealistic task.[48]

  Edward Jenner’s goal, the extinction of the variola virus, came one step closer in 1967 when the World Health Organization embarked upon the Smallpox Eradication Program (SEP). In the preceding year, approximately 15 million people had contracted smallpox, 44 countries were still reporting the disease, in 33 of those smallpox remained endemic and the annual death toll was more than 2 million. Between 1967 and 1980 intensive mass vaccination campaigns were undertaken. The strategy was to achieve 80 per cent vaccine coverage in each country. The USSR contributed over 14 million doses of vaccine and the United States contributed 190 million doses.

  As the campaign got underway, the invention of a vaccination gun that fired a jet of vaccine using compressed air was heralded because it eliminated needle replacement and sterilisation. But it was too difficult to maintain in dusty deserts. Then came the disposable ‘bifurcated needle’, which reduced the volume of vaccine required and simplified delivery. The needle’s narrow, flattened fork end drew up the exact amount of vaccine and was then jabbed repeatedly into the skin to give a painless vaccination. Teams of SEP vaccinators from all over the world journeyed to remote communities with the ambitious goal of attempting to vaccinate every person at risk. It was unachievable and in many under-developed countries real progress was hampered by wars and political unrest.

  It was a serendipitous discovery that led to a turning point in the campaign against smallpox. Insufficient vaccine supplies in Nigeria precipitated a strategy of aggressive case-finding. This involved locating people who had smallpox and then finding and vaccinating all their known and possible contacts to stop the spread. Coupled with this was surveillance containment, or ring vaccination, which meant that not every person had to be vaccinated.[49] The result was the disappearance of smallpox in eastern Nigeria even though less than 50 per cent of the population had been vaccinated.

  Using the new tactics, medical teams travelled around looking for smallpox outbreaks and put up posters advertising rewards for people who reported cases. Once found, a smallpox sufferer was isolated at home with their family and they and all surrounding families were then vaccinated. The last case of smallpox in South America was reported in 1971. The last naturally acquired cases of endemic variola major were identified in Bangladesh and India in 1975 but the disease persisted in Ethiopia and surrounding regions of Africa.

  The last case of smallpox, which was actually the less virulent strain, variola minor, occurred in Somalia in October 1977. Ali Maow Maalim, a Somali hospital worker, developed a smallpox rash. WHO officials guarded Ali’s doorstep in his small village of Merka allowing no one near him until he had recovered and the last scab had fallen from his last pock. After this, no new cases of smallpox were reported in Somalia or elsewhere. Ali Maow Maalim was declared the last person on Earth to catch smallpox by natural transmission, that is, as a result of direct contact with another human being.[50] Eradication complete?

  Not so. In 1978, two more cases of smallpox occurred in England as a result of incorrect handling of the smallpox virus in the medical school at the University of Birmingham.[51] When Janet Parker, a 40-year-old medical photographer, contracted smallpox and died in September 1978, experts were mystified. Because
the disease had already been eradicated they surmised that she must have caught it from a laboratory sample. At that time smallpox was still used in many laboratories in the world, including a laboratory on the floor below the photographic unit where Janet worked.

  An investigation showed how the virus could have moved up an unsealed ventilator shaft to a small room above the laboratory where Parker spent several hours on the day that a particular smallpox virus was cultivated. Molecular analysis of the virus that killed Janet Parker proved it was the same virus. Janet Parker’s unnecessary death had a ripple effect. Her father died of a heart attack and her mother also contracted smallpox but fortunately recovered. The virologist in charge of the laboratory, Professor Henry Bedson, head of the Department of Medical Microbiology, felt so responsible that he tragically took his own life.

  Smallpox had claimed its last victims but the incident revealed the danger that could erupt from smallpox virus stocks in laboratories. The argument for the destruction of all remaining stocks hotted up. In 1976 the World Health Organization had requested that all 76 countries holding smallpox virus either destroy or submit their stocks to one of two official WHO repositories in the United States at the Centers for Disease Control and Prevention in Atlanta, Georgia, or in the Soviet Union at the Moscow Institute. South Africa was the last to comply in December 1983.

  THE MONSTER IS DEAD

  The speckled monster was officially pronounced dead by the 33rd World Health Assembly in May 1980, when after two years of intensive surveillance in previously endemic countries no new cases had been found. Smallpox had been wiped from the face of the earth, thus fulfilling Edward Jenner’s prediction. It is said that Jenner is responsible for saving more human lives than any other person. The global eradication of smallpox is acknowledged as one of the greatest accomplishments of the twentieth century, if not one of the greatest human accomplishments of all time.