The Eradication of Smallpox

  • Herve Bazin
Academic Press, 246 pp, $49.95, 2000 ISBN 0120834758 | ISBN: 0-120-83475-8

I picked this book up with eager anticipation and put it down with a mixture of admiration and disappointment. Written by a French-speaking immunologist and translated into English, the book deals less with the eradication of smallpox than Jenner's contributions to the development of vaccination and the early history of this public health strategy. The eradication of smallpox, undoubtedly one of public health's greatest achievements, could not have occurred without Jenner's pioneering efforts in the late 18th century, but eradication was the result of international collaborative work that was only possible in the second half of the 20th century. No insight is given into the nature of the field work that went into making large countries in Africa and Asia smallpox-free, and especially into the critical strategies of disease surveillance and targeted response. The eradication campaign involved the international deployment of teams of public health workers—not all immunologists or doctors—traveling to remote parts of far away countries, looking for cases of smallpox and vaccinating to interrupt chains of transmission. This book fails to capture this essential aspect of global disease eradication—basic shoe-leather epidemiology—as relevant for polio eradication today as it was for the eradication of smallpox three decades ago. It also fails to capture the geopolitical drama behind the mounting and sustaining of a successful disease eradication program. With these deficiencies, this is a small book pretending to address a big subject.

My admiration stems from the detailed, almost loving way in which the author recounts Jenner's life and career, as well as attitudes and practices concerning smallpox in the 18th and 19th centuries. We learn of Jenner's early life in the west of England (he lost both his parents when he was five years old), of his apprenticeship to a local surgeon when barely a teenager, and his later studies with John Hunter, the famous London surgeon. Jenner became a member of the Royal Society based on his zoological and biological work, and suffered the British professional discrimination that saw surgeons as less distinguished than physicians. He never obtained a formal medical degree through studies, but eventually acquired the status of “doctor” from St. Andrews University in Scotland by getting cronies to recommend him and paying some money. Bazin recounts these and other events in an interesting style, even though his admiration for Jenner and love of the subject result in the inclusion of undisciplined detail and anecdotes that either fascinate or infuriate (the French revolutionary Marat also obtained a degree from St. Andrews; Jenner bought his cottage in Berkeley for 600 pounds sterling; his medical society gatherings were held in pubs over “a good English dinner” of pheasant or mutton—no irony apparently intended by the French author). The text includes some 120 photographs, many unlikely to be found elsewhere, some from the author's own collection.

Variolation, the intentional transmission (through inoculation) of smallpox to induce subclinical or mild infection and subsequent protection, was brought to English attention in the 1760s by Lady Montagu, wife of a British diplomat in Constantinople, who had suffered smallpox herself. This practice became widely accepted but was eventually superseded by Jenner's work based on the hypothesis derived from widespread observation and first formulated in 1798 that cowpox infection protected against smallpox. While variolation could lead to further transmission of live pox virus and itself was occasionally fatal, vaccination with cowpox was limited in clinical effect, produced a local scar indicative of response, and did not result in secondary transmission. That all this was understood before the development of microbiology as a science in the 19th century is remarkable. The strength of this book lies in the detailed description of these early events and related developments through to the 1900s.

Jenner's famous experiment involved taking pustular material from a cowpox lesion in a human (Sarah Nelmes, the author informs us) infected from a cow (Blossom), and inoculating a young boy (James Phipps). A painting of this event is described by Bazin and colleagues as “making a very pleasant picture”. These early public health experiments did not benefit from statistical and methodological principles characterizing clinical trials today, nor would they now pass ethical review boards. Bazin's evident admiration and affection for his subject again come out, and the discussion of these issues sometimes seems defensive in tone even to a reader aware that the retrospective discussion of medical practice, ethics and experimentation is fraught with difficulty.

The latter parts of the book deal, rather superficially, with global eradication, what to do with smallpox stocks remaining in the post-eradication period, and reflections on vaccination in general. This book is worth reading and having, especially for those interested in infectious diseases and public health. It is an individual labor of love and a piece of dedicated scholarship—the product, as phrased in Bazin's thanks to his family, of time spent with dusty old papers. It fails, however, to capture the reality and vibrancy of disease eradication and elimination in the modern era.