Smallpox: The Death of a Disease

  • D. A. Henderson
Prometheus Books: 2009. 334 pp. $27.98, £23.50 9781591027225 | ISBN: 978-1-5910-2722-5

On 8 May 1980 the World Health Assembly declared that “the world and all its peoples have won freedom from smallpox”. The assembly went on to express “its deep gratitude to all nations and individuals” who contributed to the success of its global vaccination programme, initiated in 1958.

One of those individuals was Donald Henderson, who directed the eradication campaign during its intensified period between 1967 and 1977. In Smallpox: the Death of a Disease, he recalls the personalities, politics and battles behind that resolution. Henderson skewers the declaration's self-congratulatory tone, quoting from Robert Burton's The Anatomy of Melancholy (1621): “When a thing has once been done, people think it easy; when the road is made, they forget how rough the way used to be.” Moreover, after success they forget their former indifference in their zeal to claim a share of the credit.

The origins of the smallpox variola virus, around 12,000 years ago, are obscure. But its influence on world history has been profound — it has killed rulers in ancient Egypt, China, Japan, Africa and Europe. Its threat was challenged in 1798 by physician Edward Jenner's discovery that infection with the related cowpox virus conferred immunity to smallpox. But outside Europe, access to this vaccine was limited early on owing to its instability.

Field workers had a vital role in the global campaign to eliminate smallpox. Credit: J. MOHR/WHO

The geographical disparities in the incidence of smallpox were highlighted in 1947 in the Weekly Epidemiological Record published by the fledgling World Health Organization (WHO), which reported that smallpox incidence was increasing in Africa, Asia and the Americas, although declining in Europe. The World Health Assembly (WHA) in 1948 established a study group on the disease at its first formal meeting. At its eleventh meeting, the Soviet Union requested that the WHO “investigate the means of ensuring the worldwide eradication of smallpox” and “encourage” the production of adequate stocks of vaccine. But progress was desultory.

Smallpox continues to hover as a dark and ominous cloud... It cannot be forgotten nor ignored.

Then, in 1965, the 18th WHA resolved that global eradication of smallpox was a major objective of the WHO. This was mainly because of altered policy in the United States — its government did not want to seem weak in those cold-war years, and the expansion of air travel increased the risk of the disease's spread. Henderson was appointed as director of that global effort. Taking up his place in medical history, Henderson moved to Geneva, Switzerland, from his post as chief of the surveillance section of the Communicable Diseases Center (now the Centers for Disease Control and Prevention) in Atlanta, Georgia.

His easy narrative is convincing, in part because of his central role but especially because of his generosity towards the numerous other participants — he portrays the 'front-line troops' in the field as being even more important than those at WHO headquarters. His magnanimity makes his criticisms all the more trenchant and cogent.

Anyone can be blinkered to the real problems of the world when they observe them from a comfortable office in a prosperous society — and that is true of governments as well as individuals. Henderson's accounts of inefficiencies and hostility are dispiriting: the failure of one government to admit that a locally made vaccine was useless and thus dangerous; the insistence by another that home-manufactured vehicles must be exported to distribute that nation's aid, adding costs, delays and interruptions to the work; and the arrogance and obstruction of individual health officials.

The achievement — with dizzying statistics of the hundreds of millions of doses of vaccine that were distributed — becomes all the more admirable when Henderson describes the physical obstacles that were overcome. His relationships with people across many nationalities and backgrounds were a crucial factor. The imaginative recruitment of schoolchildren, for example, is particularly striking: they tend to know the goings-on in their communities and, unlike officials, can be relied on to say what is really happening.

There is a second act to Henderson's drama that is linked to the power politics that prevailed at the end of the cold war. In May 1980, the WHA urged “the discontinuation of smallpox vaccination” and resolved that no more than four WHO collaborating centres should hold and handle stocks of smallpox virus. This raised the question of which countries should hold this potential bioweapon, one being the United States. Yet, in accord with the WHO resolution, the majority of the US population by this time had no immunity to smallpox. By then, Henderson had returned to the United States as a senior academic and later became adviser to President George H. W. Bush. Regrettably, here he is the epitome of discretion. He names few people, but does reveal his experience of the chilling intransigence and medical ignorance shown by the Pentagon in its negotiations with him over biological warfare policies.

Like all good stories, Smallpox recounts the deeds of heroes and villains, fools and sages. Henderson ends by declaring his pride in having been at the WHO at this crucial time. A better conclusion would have been the close of the penultimate chapter, in which his delight is tempered with a dash of reality: “smallpox continues to hover as a dark and ominous cloud as it has throughout the course of mankind's history. It cannot be forgotten nor ignored”.