The End of a Global Pox: America and the Eradication of Smallpox in the Cold War Era

By Bob H. Reinhardt

By the mid-twentieth century, smallpox had vanished from North America and Europe but continued to persist throughout Africa, Asia, and South America. In 1965, the United States joined an international effort to eradicate the disease, and after fifteen years of steady progress, the effort succeeded. Bob H. Reinhardt demonstrates that the fight against smallpox drew American liberals into new and complex relationships in the global Cold War, as he narrates the history of the only cooperative international effort to successfully eliminate a human disease.

Unlike other works that have chronicled the fight against smallpox by offering a "biography" of the disease or employing a triumphalist narrative of a public health victory, The End of a Global Pox examines the eradication program as a complex exercise of American power. Reinhardt draws on methods from environmental, medical, and political history to interpret the global eradication effort as an extension of U.S. technological, medical, and political power. This book demonstrates the far-reaching manifestations of American liberalism and Cold War ideology and sheds new light on the history of global public health and development.

• Language: English
• Publisher: The University of North Carolina Press
• Release date: Jun 24, 2015
• ISBN: 9781469624105

Bob H. Reinhardt

Bob H. Reinhardt is assistant professor of history at Boise State University.

Book preview

The End of a Global Pox

FLOWS, MIGRATIONS, AND EXCHANGES

Mart A. Stewart and Harriet Ritvo, editors

The Flows, Migrations, and Exchanges series publishes new works of environmental history that explore the cross-border movements of organisms and materials that have shaped the modern world, as well as the varied human attempts to understand, regulate, and manage these movements.

The End of a Global Pox

America and the Eradication of Smallpox in the Cold War Era

Bob H. Reinhardt

The University of North Carolina Press

Chapel Hill

This book was published with the assistance of the Lilian R. Furst Fund of the University of North Carolina Press.

© 2015 The University of North Carolina Press

All rights reserved

Set in Miller by codeMantra, Inc.

Manufactured in the United States of America

Chapter 2 appeared previously in somewhat different form as Bob H. Reinhardt, The Global Great Society and the US Commitment to Smallpox Eradication, Endeavour: The History and Philosophy of Science 34, no. 4 (December 2010): 164–72.

The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources. The University of North Carolina Press has been a member of the Green Press Initiative since 2003.

Jacket illustration: Woman being vaccinated for smallpox during a 1968 African vaccination campaign (courtesy Centers for Disease Control and Prevention)

Library of Congress Cataloging-in-Publication Data

Reinhardt, Bob H., 1978– , author.

The end of a global pox : America and the eradication of smallpox in the Cold War era / Bob H. Reinhardt.

p. ; cm. — (Flows, migrations, and exchanges)

America and the eradication of smallpox in the Cold War era

Includes bibliographical references and index.

ISBN 978-1-4696-2409-9 (cloth : alk. paper) — ISBN 978-1-4696-2410-5 (ebook)

I. Title. II. Title: America and the eradication of smallpox in the Cold War era.

III. Series: Flows, migrations, and exchanges.

[DNLM: 1. Disease Eradication—history—United States. 2. Smallpox—prevention & control—United States. 3. Global Health—history—United States. 4. Health Policy—history—United States. 5. History, 20th Century—United States. 6. History, 21st Century—United States. 7. International Cooperation—history—United States. 8. Politics—United States. WC 588]

RC183

362.1969’12—dc23

2015006182

Contents

Acknowledgments

Abbreviations and Acronyms

INTRODUCTION

Dark Winter

CHAPTER ONE

Becoming a Suitable Candidate for Global Eradication

CHAPTER TWO

A Global Great Society and the U.S. Commitment to Eradication

CHAPTER THREE

The CDC and Smallpox Eradication in West and Central Africa

CHAPTER FOUR

Mutual Understanding and the Final Phase of Eradication

CHAPTER FIVE

A Suitable Candidate for Global Terror

EPILOGUE

Celebrating a Complicated Legacy

Notes

Bibliography

Index

Illustrations

Variola, the virus that causes smallpox, 7

The sight and suffering of smallpox, 8

Smallpox on the Black Continent, 41

Vaccination by jet injection, 68

Vaccination by bifurcated needle, 76

Celebrating vaccination and cooperation, 97

Gambia River versus Dodge truck, 102

Rationalizing nomadism, 104

Coercing cooperation, 145

Confirming and learning from smallpox eradication, 166

The specter of smallpox, 177

Looking toward freedom from smallpox, 191

Figure, Maps, and Table

FIGURE

Reported Cases of Smallpox, 1920 to 1958, 24

MAPS

The Nineteen Countries of the CDC’s Smallpox Eradication and Measles Control Program in West and Central Africa, 54

The Disappearance of Smallpox, 1966 to 1977, 126

TABLE

Contributions to the WHO’s Smallpox Eradication Programs and to Bilateral Smallpox Eradication Programs, 1967–79, 137

Acknowledgments

My deepest thanks to Ari Kelman. Among the innumerable ways in which he made this book possible: he gave me the idea for this project, provided access to funding, patiently read and thoughtfully commented on many different versions of the text (as dissertation and book manuscript), and suggested myriad improvements in analysis, narrative, and prose. This project is as much his as it is mine—the good parts, anyway; the book’s many faults are mine alone. I could not have asked for a better mentor or friend, and I will always be in his debt.

I am grateful for three other outstanding mentors: Caroline Acker, Kathy Olmsted, and Louis Warren. Caroline advised manuscript revisions and career decisions as my postdoctoral fellowship mentor at Carnegie Mellon University; she also acted as surrogate family for my wife, children, and me while we lived in Pittsburgh. Her insights as a historian of medicine dramatically improved this book, and her friendship made our time in Pittsburgh an immense joy. As cochair of my dissertation committee, Kathy provided thoughtful critiques, suggestions, and ideas, particularly about the larger framing of the book, helpfully reminding me that smallpox eradication is, in fact, a very good thing! She constantly supported me during and after my time at UC Davis, and she has been a great friend. Louis, too, has been a marvelous mentor and friend, and I cannot thank him enough for his help as dissertation reader and for his general counsel on my project and career.

My sincere thanks to the many advisors who have guided me through the development of this book and my academic career, including Eric Rauchway, Alan Taylor, Chuck Walker, and Clarence Walker at UC Davis; Matthew Dennis, Jeff Ostler, and Daniel Pope at the University of Oregon; and Ellen Eisenberg, Bill Duvall, and Bill Smaldone at Willamette University. Other colleagues and friends at Willamette University gave me the time, space, and encouragement that I needed to complete my dissertation and work on this book while I taught there, and I thank them: Wendy Peterson Boring, John Braun, Robert Chenault, Seth Cotlar, Jennifer Jopp, Ron Loftus, Cecily McCaffrey, and Bianca Murillo in the Department of History; Karen Arabas, Joe Bowersox, Kimberlee Chambers, Melissa Hage, Scott Pike, and Zack Taylor in the Department of Earth and Environmental Sciences; and Monique Bourque, David Douglass, David Gutterman, Briana Lindh, Jennifer Johns, Joyce Millen, Scott Nadelson, and Andrea Stolowitz elsewhere on campus. Special thanks to Leslie Dunlap and Maggie Powers for their leadership of the Steering Committee for Social Affairs and their support through myriad challenges.

I subjected far too many students at Willamette University to different drafts and portions of this project, and I thank them for their patience and insights, particularly participants in my course Health and the Environment in U.S. History. Thanks also to students in the classes I taught at Carnegie Mellon University, who challenged me to develop my skills in the history of health. I am grateful, too, for the opportunity to have discussed this project with graduate students at Carnegie Mellon, including those in the environmental history working group. I am also thankful for friends at CMU, including Robert Hutchings, Ricky Law, and Jay Roszman—all brilliant scholars and wonderful people.

I thank the Department of History at Carnegie Mellon University for providing time, space, and many forms of support while I held the A.W. Mellon Fellowship in the Humanities. My sincere thanks to the Mellon Foundation for supporting that program, which allowed me to finish this book. I am also grateful for generous financial support from the Institute of Governmental Affairs at UC Davis, from the UC Davis Department of History in the form of Reed-Smith Dissertation and Research Travel Fellowships and the W. Turrentine Jackson Fellowship, and for conference travel grants from the National Science Foundation and the National Park Service. Thanks also to Summer Oakes for free accommodations in Austin and to Ari Kelman for a loan I hope to someday repay.

Archivists and librarians make the work of historians possible, and I thank all of those who have helped with this project: Allen Fisher at the Lyndon B. Johnson Presidential Library; Tomas John Allen, Josette Curtet, Reynald Erard, Marie Villemin Partow, and Anne-Emmanuelle Tankam-Tene at the World Health Organization; David Fort, Veronica Hewlett, and David Pfeiffer at the National Archives and Records Administration in College Park; Mary Hilpertshauser and Michelle Lowe at the Centers for Disease Control and Prevention’s Global Health Odyssey Museum; and Francis Alba and Mary Wilke at the Center for Research Libraries. Thanks to Anastasia Ruvimova for Russian translation and Daniel Berg for research assistance and to Sue Cale and Gail Tooks at CMU, Elizabeth Bacon and Ross Eikenbary at UC Davis, and Leslie Cutler and Mary Plank at Willamette University for administrative and emotional support.

I am in debt to those who shared their personal experiences with smallpox eradication and their thoughts on that remarkable accomplishment. D. A. Henderson has been especially generous, meeting and corresponding with me often and reviewing different iterations of this project, despite our different stories and understandings of smallpox eradication. Pat Imperato shared many stories from his remarkable life, from eradication in Mali to treating ballplayers with the Los Angeles Dodgers, and I thank him for his support and insights. Thanks also to Joseph Califano, Bill Foege, Philip Lee, and Michael Osterholm for speaking with me about smallpox and its eradication and to Joseph Esposito and John Wicket for helping me track down research leads. To everyone who participated in smallpox eradication, from the politicians and planners to the vaccinators and patients, thank you for freeing the world of a horrible disease.

Many people have heard, read, and critiqued this book at different stages of development, and I thank them for their encouragement and suggestions: Dawn Biehler, Paul Cruickshank, Urmi Engineer, Mariola Espinosa, Etienne Gosselin, Jeremy Greene, Margaret Humphreys, Chau Kelly, Matt Klingle, Neil Maher, Gregg Mitman, Randy Packard, Steven Palmer, Liza Piper, Samantha Scott, Chris Sellers, Tamara Venit-Shelton, and James Webb. Thanks in particular to Sanjoy Bhattacharya, Paul Greenough, and Erez Manela, who have written (and continue to produce) excellent histories of smallpox eradication and who have generously shared their ideas and offered suggestions for my project. I thank the anonymous reviewers of the book manuscript and various articles derived from this project; they devoted significant time and energy to the task, and I deeply appreciate their critiques and suggestions. I am also grateful for ideas and inspiration from Pat Manning, Christian McMillen, Amelia Kerns, Josh Silverman, John Soluri, and Emily Wakild. Thanks to all of these people—and to those I have forgotten to include—for making this project immensely better and for trying to steer me in the right direction.

It is my great good fortune to have UNC Press publish this book, and I thank everyone there, especially Mark Simpson-Vos, who supported the project very early on and patiently tolerated my many delays, and Brandon Proia, who has guided me through the final stages of the project. Thanks also to Susan Ferber at Oxford University Press, who generously offered her time and encouragement.

I have been blessed with friends and family who have supported me at every turn. At UC Davis, thanks to Chad Anderson and Jakub Benes for keeping me out too late, Nate Carpenter for commiserating at American Historical Association meetings, Christian Castro for instruction in the nuances of fútbol and our profession, Adam Costanzo for dog watching and moderate reality checks, Steve Cote for humor and perspective, Andy Denning for his sage advice and constant support through all my grousing and complaining, Jordan Lauhon for bike rides and barbecues and so much more, Shelley McCabe for making us feel at home in Davis, Miles Powell for a Canadian approach to life and environmental history, Josh Reid for his advice as peer and friend, Alison Steiner for carrying me through the wilderness (figuratively and literally), and Paul Richter for theory and music. I am also grateful for my friends outside of academe who have put up with this ridiculous project and career of mine: Bryan Barnett, Ty Hibbard, and Nat Tilden, whose supportive calls of hey always lift my spirits; Shannon Forestall and Chuck Williams, always willing to lend a neighborly hand and drink a neighborly beer; Jeanne Jameson, who has seen me and my work through too many ups and downs; Amy Rockwell, for letting me hang around her house and husband more often than I should; and Spencer Rockwell, whose friendship and unwavering support since junior high school has given me strength and confidence that I could never fully calculate nor repay. Thanks to Mom, Dad, Mimi, Gramps, Grampa, Gramma, Kris, Drew, Sue, Myles, and Sheila for providing the kind of patience and support that only family can give and which I will always need. Violet and Liam were born while I wrote this book, and their giggles and cries have always helped put my work (and smallpox eradication more specifically) in perspective. Thanks for making your dad a better scholar and person. Finally, I thank Leah. She has put up with long-distance moves away from family, tolerated my early mornings and late nights at the computer, assisted with research in Geneva and helped pack my bags for other trips, supported our family during lean times, brought me water, coffee, or beer depending on my mental state, and so much more—all while maintaining an attitude of optimism and confidence, without which I never would have started or completed this project. I cannot adequately express my gratitude to her in words, but since that’s all I have, thank you.

Abbreviations and Acronyms

AIDS acquired immune deficiency syndrome APHA American Public Health Association CDC Centers for Disease Control and Prevention (known as the Communicable Disease Center before 1970) DDT dichloro-diphenyl-trichloroethane EIS Epidemic Intelligence Service EPI Expanded Programme for Immunization FDA U.S. Food and Drug Administration GPEI Global Polio Eradication Initiative HEW Department of Health, Education, and Welfare IDSA Infectious Disease Society of America IHA International Health Act of 1966 LDC less developed country LNHO League of Nations Health Organization MVA modified vaccinia Ankara NIH National Institutes of Health NSC National Security Council NSTC National Science and Technology Council OCCGE Organisation de Coordination et de Coopération pour la Lutte contre les Grandes Endémies OIHP Office International d’Hygiène Publique PAHO Pan American Health Organization PASB Pan American Sanitary Bureau PHS Public Health Service PL 480 Public Law 480 RIVP Research Institute of Viral Preparations SEP Smallpox Eradication Program SMP Smallpox Eradication and Measles Control Program UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHA World Health Assembly WHO World Health Organization

The End of a Global Pox

Introduction

Dark Winter

In June 2001, Andrews Air Force Base hosted an unusual role-playing game that featured a surprising lead actor. Developed by the Johns Hopkins Center for Civilian Biodefense Studies, the two-day exercise, called Operation Dark Winter, meant to test U.S. preparedness for a major biological attack on the American homeland.¹ Participants brought their backgrounds in politics, the military, and medicine to play different roles in the exercise; among them were retired senator Sam Nunn, who became, for a day, the president of the United States (very likely fulfilling a lifelong fantasy); Dr. Margaret Hamburg, assistant secretary for planning and evaluation at the Department of Health and Human Services, who became full secretary for the exercise; and Oklahoma governor Frank Keating, joining the exercise as himself. As participants settled into their roles and their seats on the mock National Security Council (NSC), they received a variety of memos and briefings updating them on the current global situation: escalating tensions in the Taiwan Strait and on the Iraq/Kuwait border, reports of bioweapons production in Iraq, and news that Russia had recently arrested a suspected senior lieutenant of Usama bin Laden for attempting to acquire both plutonium and biological weapons from the now-dissolved USSR. The Iraq/Kuwait border crisis should have dominated the NSC meeting, but President Nunn had just informed participants of something unimaginable: smallpox, a disease ostensibly eradicated from the world in 1977, had reappeared in Oklahoma.

One hour before the meeting, Secretary of Health and Human Services Hamburg told the president that the Centers for Disease Control and Prevention (CDC) had confirmed the presence of smallpox in Oklahoma City. This is an extremely serious situation, President Nunn told the NSC players, reminding them that because smallpox no longer exists in nature, very few people had directly experienced or been vaccinated against the disease, and so very few people possessed any immunity to smallpox. The World Health Organization’s global Smallpox Eradication Program (SEP), an international effort to eliminate the disease initiated in 1958, isolated the last naturally occurring case of smallpox in 1977, thereby removing smallpox from the global disease environment. The SEP had then handed variola, the virus that causes smallpox, over to virologists in the United States and Russia who were supposed to keep it under lock and key. But something had gone terribly wrong. Had there been a containment or security failure at one of the two labs that still possessed smallpox samples? A hidden virus sample that had escaped the SEP’s grasp? A rogue former Soviet scientist selling his expertise and virus collection to a bioterrorist, perhaps related to the problems in the Pacific and the Middle East?

Though the precise origin of the attack remained unknown, a sharper picture of the outbreak began to emerge. The first case of smallpox had appeared one week earlier, and since then, twenty people had been diagnosed with the disease. Governor Keating of Oklahoma then provided more information to the bewildered audience. Local news media were running nonstop reports on the outbreak; anxious citizens had flooded emergency rooms; some hospital staff refused to return to work for fear of infection. The situation was spiraling out of control. Governor Keating demanded enough vaccine from the CDC’s stockpile to protect all of his state’s 3.5 million residents, and he declared a state of emergency. He suggested that President Nunn do the same, before the outbreak became totally unmanageable.

Governor Keating then gave the podium to two officials from the Department of Health and Human Services (DHHS), played by Dr. Thomas Inglesby and Dr. Tara O’Toole of the Johns Hopkins Center for Civilian Biodefense Studies, one of the sponsors of the exercise. Inglesby quickly reviewed the history of smallpox—which, he said, had killed 300 million people worldwide in the twentieth century—and then moved on to harrowing information about the disease’s etiology and effects. Smallpox spreads by inhalation, usually transmitted from person to person. Once infected, a smallpox carrier incubates the disease for anywhere between nine and thirteen days before the appearance of a rash that at first looks a bit like chickenpox. At that point, and until the disease runs its course two or more weeks later, the victim unwittingly spreads the virus with every cough and gasp of breath. Exaggerating slightly for the purposes of the exercise, Inglesby explained that smallpox moves rapidly, progressing geometrically; one person could spread it to as many twenty more victims, each of whom might infect twenty more, and so on. In the few precious minutes since the beginning of the NSC meeting, more cases had appeared: fourteen additional victims in Oklahoma, plus nine in Georgia and seven in Pennsylvania. At best, these patients would survive with scarring or perhaps permanent blindness. But one in three victims, Inglesby reported, would probably die.

Worse still, there was little that the NSC, the president, or anyone else could do about the outbreak. Smallpox does not respond to antiviral drugs or any other treatment. A victim can do little more than hope that he or she will survive the month-long course of the disease. Humanity could only rely on the line of defense it had maintained for more than a century before smallpox’s alleged eradication: vaccination. A few pricks of the arm with vaccinia, the inoculating virus, would protect a person from variola, the smallpox virus. The vaccine was remarkably effective; its power helped make global smallpox eradication possible. But the United States did not have enough vaccine to go around. Since the declaration of victory over smallpox nearly thirty years before, drug companies and governments had stopped producing any vaccine and had destroyed much of their remaining stocks. There remained only 12 million doses in the entire United States—nowhere near enough to protect the more than 35 million residents of the three states infected with the virus, much less the rest of the country. Inglesby and O’Toole held out little hope for more vaccine arriving anytime soon; the rest of the world would surely cling to its meager 60 million doses, and even though President Nunn had waived all U.S. Food and Drug Administration (FDA) safety regulations, it would still take more than a month to begin domestic production of new doses of the vaccine. The United States could not hope to beat smallpox back into the grave.

And so the NSC turned to the painful question of which lives to save. Governor Keating wanted enough vaccine for the entire state of Oklahoma, and the governors of Georgia, Pennsylvania, and other states would surely demand the same. The Secretary of Defense, played by former deputy secretary of defense John White, requested 2.5 million doses to protect the armed forces; Secretary of State Frank Wisner, drawing on his extensive service as an ambassador and State Department official, asserted his own agency’s vital need for prophylaxis. Secretary of Health and Human Services Hamburg and her staff insisted on vaccination of hospital staff and first responders, who were risking their own lives to contain a disease they had never seen and against which they possessed no immunity. Hamburg’s staff also advocated a tactic—last seen during the global eradication campaign—called surveillance and containment, in which public health workers would identify the foci of the outbreak and vaccinate everyone who had come into contact with suspected cases. That approach, of course, denied the vaccine to people outside the surveillance areas, thereby accepting the possibility of some infection and death before containment procedures could begin. Attorney General George Terwilliger (once a deputy attorney general for George H. W. Bush) noted that Hamburg’s recommendation did not explain how, exactly, to deploy such a tactic. Would state or federal authorities take responsibility? Would vaccination be voluntary or mandatory? Who would enforce the necessary quarantine measures?

The NSC, though, quickly set aside questions of civil liberties and settled on a makeshift plan. First, vaccinate the residents of the three infected cities (Oklahoma City, Philadelphia, and Atlanta). Second, provide enough vaccination for surveillance and containment measures in those three areas. Third, reserve 2.5 million doses for the military. Finally, distribute 125,000 doses of vaccine on a per capita basis to all other states. That left just 1.4 million doses, and smallpox had not yet struck the next round of victims.

Smallpox spread quickly in the following days, sped up for the purposes of the exercise. Within a week, the disease had infected more than 2,000 people in fifteen states; it also appeared in Canada, Mexico, and the United Kingdom, carried by unwitting travelers incubating the virus. By the twelfth day of the outbreak, seven more countries had reported smallpox infections, and more than 16,000 cases had been reported in twenty-five different states. At this rate, and based on historical precedent, the epidemic would spread to more than 3 million people throughout the world in less than two months. The NSC’s plan had failed; smallpox was utterly out of control. Panic broke out. The Governor of Texas, saying I am left with no alternative, ordered the National Guard to close the border with Oklahoma, and he urged the governors of New Mexico, Colorado, Kansas, Missouri, and Arkansas to do the same. Foreign governments had already taken such measures, rejecting not only American citizens but also American goods from ports of entry throughout the world. The U.S. economy ground to a halt as businesses, banks, and post offices closed. Hospitals shut their doors too, as even essential personnel refused to enter infected buildings, and facilities that remained open buckled under the pressure of the exponential increase in demand.

Anxiety gave way to violence, as the game inevitably spiraled out of participants’ control. Mock videos showed riots in Philadelphia, where citizens demanded immediate access to dwindling vaccine supplies; in New York City, five people died during a shootout between an infected family and police officers enforcing quarantine measures. But guns could not match smallpox’s lethality. As the exercise played out, 10,000 people succumbed to the disease within a month; just two weeks later, smallpox had claimed the lives of more than 100,000 people. Dr. Tara O’Toole from the DHHS/Johns Hopkins Center for Civilian Biodefense Studies predicted that within two months, in excess of 1 million people would die from the outbreak. O’Toole suggested that her estimates might even be too conservative, noting that the Aztecs had lost nearly half their population of 25 million to smallpox. Before the epidemic ended—if, indeed, the world could stop it—millions more would die of a disease that should, the experts sighed, have long since been eradicated.

THANKFULLY, OF COURSE, none of the above happened. In June 2001, smallpox remained effectively extinct, thanks to the decade-long global eradication program that had achieved victory in 1977. Dark Winter was only a game—oversimplified and melodramatic, but, as participants related in the wrap-up session and in congressional testimony, terrifying nevertheless. The perilous situation faced by the posteradication world was quite real, because, despite the global eradication program’s success, smallpox continued to threaten humanity. The disease no longer existed, it was true, but the virus lived on. Because of purported needs for more scientific research, as well as mistrust between the United States and the USSR at the end of the eradication program, the smallpox virus had been preserved in a laboratory at the CDC and a similar facility in Russia. But some experts feared that the virus might also lurk in the shadows of unknown Cold War–era biological weapons programs; perhaps disaffected and underpaid Soviet scientists ferreted away a sample as the USSR crumbled. Moreover, very few people possessed immunity to smallpox, because regular vaccination, the only reliable protection against smallpox, had ended shortly after declaration of eradication’s success. Dark Winter revealed a tragic irony: that the global eradication program itself had created a world in which smallpox seemed to represent a dire threat.

AN AGE-OLD SCOURGE

By the time of the Dark Winter exercise in 2001, no one had seen a case of smallpox in more than twenty years, a state of affairs worth celebrating, because smallpox had once been a frightful and gruesome killer. The disease was caused by the variola virus, a member of the orthopoxvirus family, which also includes cowpox, monkeypox, and camelpox. Unlike its cousins, though, variola only infected humans, and it usually did so through the air, inhaled at close contact—within approximately seven feet—by its victims. Once inside the respiratory system, variola spread to the lymph nodes and then attacked the body. Smallpox did what all viruses do: it invaded and took over the body’s cells, using their reproductive processes to replicate the virus’s genetic code and spread infection throughout its host. In the ten to fourteen days of this colonization, a smallpox victim usually felt perfectly normal, showing no signs of illness or infection. Then, quite suddenly, symptoms appeared: high fever, severe headache and backache, sometimes delirium and nightmares. After a few days, symptoms subsided in a deceptive respite, before smallpox resumed its attack in earnest, with manifestations of its rash, first inside the mouth and on the tongue and then across the victim’s skin.²

Although today, unsuspecting physicians might mistake the early rash for chickenpox, health care professionals who encountered the disease before eradication knew it immediately: concentrated on the extremities (rather than the body’s center, as with chickenpox), the flat red rash transformed into raised bumps, filled with pus, which then hardened into pustules that were firm, round, and painful to the touch. In some cases—about 10 percent—the rash and pustules were not severe; these victims carried a different type of smallpox called variola minor, which has a mortality rate roughly equivalent to chickenpox. But variola major offered its victims much less hope. Most were left with telltale scars on the face after enduring a week or more of the painful pustular stage before the pocks began to scab over and fall off. Other victims were blinded in one or both eyes by the disease. Historically, around a quarter of those infected with variola major died, as the virus took control of cells throughout the skin, lungs, heart, liver, and more. Some died from a particularly gruesome form of the disease called hemorrhagic smallpox, during which layers of skin slipped off as the victim experienced massive internal and external bleeding. It was for good reason that Thomas Jefferson called it the loathsome smallpox.³

Variola, the virus that causes smallpox. This image shows a single virus particle as captured by electron microscope and magnified 310,000 times. (Centers for Disease Control and Prevention Public Health Image Library, ID 8392, http://phil.cdc.gov. Electron photograph by James Nakano, CDC, 1968.)

Smallpox produced terror wherever and whenever it struck. The Aztecs recounted the horror of smallpox, brought to Mexico’s capital Tenochtitlan in 1519 by Cortez’s infected soldiers: Sores erupted on our faces, our breasts, our bellies; we were covered with agonizing sores from head to foot. . . . The sick were so utterly helpless that they could only lie on their beds like corpses, unable to move their limbs or even their heads. . . . If they did move their bodies, they screamed with pain.⁴ In the memory of the Kiowa people of the southern Great Plains, smallpox appears as a stranger in a black suit, warning that to men I bring not death alone but the destruction of their children and the blighting of their wives. The strongest warriors go down before me. No people who have looked at me will ever be the same.⁵ During the American Revolution, John Adams lamented his nation’s helplessness in the face of the disease: The Small Pox is ten times more terrible than Britons, Canadians and Indians together. . . . The small Pox! The small Pox! What shall We do with it?⁶ Centuries later, Americans remained in awe of the disease’s power; during the last major U.S. outbreak in 1947, the mayor of New York called on the secretaries of war and the navy for assistance.⁷ And the person who led the global eradication campaign in the 1960s and 1970s, Dr. D. A. Henderson, recalls clearly his first interaction with the disease: The ugly, penetrating odor of decaying flesh . . . the hands, covered with pustules, reaching out, as people begged for help.⁸ The terror of smallpox left its horrible marks on the psyche as well as on the body.

The sight and suffering of smallpox. This Bangladeshi child, photographed in 1975 during the global eradication campaign, shows a typical case of variola major at approximately the tenth day of the rash. The skin is covered by raised pustules, some of which have opened. (Centers for Disease Control and Prevention Public Health Image Library, ID 12290, http://phil.cdc.gov. Photograph by Dr. Michael Schwartz, CDC, 1975.)

Smallpox produced such fright in part because it yielded to neither treatment nor cure. Herbalists, folk doctors, and scientists alike had offered their own elixirs and potions for the disease, but none succeeded in slowing, much less stopping, the virus’s assault. The most popular treatment, erythrotherapy, supposedly worked its effects through color: patients were surrounded with red blankets, red wall coverings, red clothes, red lights. Red therapy provided as much protection from the disease as mail-order smallpox cures, which is to say, none at all. Good nursing care—cleaning wounds to prevent additional infections, providing food and water, and comforting the victim through a terrifying and painful experience—alleviated some suffering and could improve one’s chance of survival, but there was no way to cure