Having lost the campaign to fight against pure food and drugs, the group redirected itself against vaccines. The Truth Teller peddled outrageous stories of the evils of vaccination as described by an expose in the July 29, 1922 Journal of the American Medical Association. In an investigation conducted by the American Medical Association’s Bureau of Investigation, the prestigious medical organization refuted the supposed “authentic facts” conveyed in The Truth Teller.77 This expose also revealed advertisements featured in the Truth Teller were strikingly similar to those from the Peril except that they focused on alternatives to vaccines that were not subject to regulation by the 1906 Federal Pure Food and Drug Act. Sadly, the very real suffering and animus felt by the followers of Lora Little were exploited by the Truth Teller and Lora Little herself, who sold a series of additional publications on the perils of vaccines to a gullible public.
There was some validity to the argument that vaccination could be harmful. As we will see in a future chapter, the state of the art in the manufacturing of vaccines was wholly unregulated in turn-of-the-century America. Like any industry, vaccine distributors covered a wide range, from large factories to smaller companies run out of a kitchen or garage. Many were not much more evolved than the situation at the beginning of the 19th century, when Jefferson collected the pus from his vaccinated slaves to propagate vaccination in subsequent waves of “volunteers.” An unregulated practice meant that some vaccines were indeed unsafe, and the specific sources supplying the vaccines used on Kenneth Little and Raymond Pitcairn have long since been lost to the ages. Such concerns about the manufacturing and quality of vaccines would remain for years to come, until they were finally resolved by a calamity that would claim the lives of children in St. Louis, Missouri, as we will sson see.
Despite the fact that neither Pitcairn nor Lora Little had advanced educations or a scientific or medical background, Pitcairn’s resources, combined with Little’s sincere passion and a tiny grain of scientific support, gave rise to the anti-vaccinator cause. These resources incubated the growth of an opposition that grew vigorously throughout the mid-1800s. The evidence that this opposition was quite effective is demonstrated by rising rates of smallpox infection in the United States in the second half of the 19th century (the disease had almost been eradicated but made a deadly resurgence).78 Taking the position that the common man should decide whether to be vaccinated, the movement was underwritten by a handful of wealthy demagogues until it was finally stopped in its tracks by the 1905 Supreme Court decision Jacobson v. Massachusetts, which ruled that compulsory vaccination was in the best interest of the state.79
Although largely eliminated in the United States by the early years of the 20th century, smallpox made a frightening return eighteen months after the end of the Second World War. On February 24, 1947, Eugene Le Bar and his wife boarded a bus in Mexico City. They were returning to Maine after a successful Central American vacation. During the bus ride, Eugene started feeling poorly, but when they arrived in New York, he felt good enough to check into a Midtown hotel and go shopping on Fifth Avenue. By May 5, Eugene had developed a rash and was admitted to Bellevue Hospital in Manhattan with a diagnosis of chicken pox.80 Mr. Le Bar was then transferred to another hospital, Willard Parker, but within days, the patient was dead. A few days after his passing, a worker at Willard Parker was diagnosed with a similar rash, which was recognized as smallpox. Hoping to avoid panic, the officials conducting Le Bar’s autopsy had listed the cause of death as hemorrhagic bronchitis, but a series of people who had encountered Eugene, either directly or otherwise, were diagnosed with smallpox. Officials scrambled to identify people within the city of New York with whom he had had direct or indirect contact (at the hotel, department store, or hospitals), as well as fellow bus riders from Mexico City. In an attempt to vaccinate individuals potentially exposed to smallpox, newspapers and radio stations communicated the message to an anxious public. Unsurprisingly, anxiety grew, and the health department was unprepared to procure or distribute millions of vaccine doses. In what is still regarded as a masterful demonstration of a high-functioning public health system, the city was able to deploy its limited supply of vaccines in a manner that protected the most vulnerable population while calming the public and avoiding panic.81 This admirable performance during the 1947 outbreak would also prove to be the final chapter in America’s long history with smallpox.
Utter Eradication
Over time, the use of the smallpox vaccine would gain acceptance worldwide. Given the geography and ties to Jenner’s England, many European countries were the quickest to embrace the practice of vaccination, both for their homeland populations and beyond. The Spanish king Charles IV was an early adopter. His motivation was based in part on the experiences of his daughter, Maria Teresa, the Infanta of Spain, who died from smallpox on November 2, 1794 at the age of five. Upon learning of Jenner’s discovery, Charles directed the Spanish government to initiate a successful domestic immunization campaign. Given its many ties to the New World, Spain then launched the three-year Balmis Expedition, so named for its leader, physician Dr. Francisco Javier de Balmis, who was dispatched in 1803 to vaccinate millions in Spain’s American colonies in South and Central America, as well as Spanish possessions in the Philippines and China.82
Most of the developed world likewise utilized a gauntlet of immunization and monitoring to eliminate or limit what had been periodic and devastating epidemics of smallpox. However, the disease lingered in many of the less affluent and developed countries. A century and a half after the Balmis Expedition, the 19th World Health Assembly of the World Health Organization (WHO) launched a measure intended to eradicate smallpox forever. The rationale behind this daunting challenge was formulated in the first meeting of the organization in 1948 (coincidentally just after that the Le Bars were planning their Mexico trip that would later cause the last case of smallpox in the United States). The goal of the program was unprecedented: To intentionally and forever eliminate an organism from the face of the Earth.
The ability to eradicate the disease altogether was a fortuitous opportunity based upon a peculiar aspect of smallpox biology. While we will discuss the biology of viruses in a subsequent chapter, a key feature that rendered smallpox susceptible to eradication is the fact that smallpox can only be propagated in humans. This feature likely represents a dramatic development within the past fifty thousand years or so. Initially a rodent virus, the smallpox virus gained the ability to grow in humans but lost the ability to do so in rodents.83
The selectively of smallpox for humans meant that there was no disease reservoir, other than people, where the virus could hide. Stated another way, stop smallpox in humans and the virus goes away—forever. In the midst of the Cold War, the United Nations initiated a campaign that would unite humanity with the goal of eliminating the deadly scourge of smallpox. However, it didn’t necessarily start that way.
Both the United States and the Soviet Union actively sought to eliminate smallpox in their own countries and then around the world. As part of each rival’s outreach to court nonaligned nations, they launched their own programs in part to inspire goodwill from potential strategic partners. The United States launched smallpox eradication efforts in South America and western Africa, both of which were paying considerable dividends in terms of public health successes, goodwill, and propaganda value.84 Not to be outdone, the Soviet Union vocally lobbied the United Nations to direct its public health entity, the World Health Organization, to eliminate smallpox across the globe. The WHO, ever a highly political and rather insecure organization, was averse to an endeavor whose risk level was comparable to its high-profile nature. Indeed, the WHO had previously failed in their attempts to similarly eliminate regional outbreaks of yellow fever and malaria, and the prospect of a global program caused eye and stomach rolling in many in the WHO leadership.
Nonetheless, the pressure to support the program intensified as the United States joined its Soviet rivals in advocating
for a global program to eliminate smallpox.85 As American pressure increased, the Brazilian director-general and infectious disease specialist Marcelino Candau called upon an American to lead the program. In an open message to the United States surgeon general, William H. Stewart, in early 1966, Candau demanded, “I want an American to run the program because when it goes down, when it fails, I want it to be seen that there is an American there and that the U.S. is really responsible for this dreadful thing that you have launched the World Health Organization into, and the person I want is Henderson.”86
The Henderson that Candau insisted upon was Donald A. Henderson, known to his friends as “D.A.” Henderson was a physician, who admitted that his first “real job” began after he completed his medical residency in the mid-1950s and started working for the Epidemic Intelligence Service of the Communicable Disease Center (later known as the Centers for Disease Control and Prevention, or CDC).87, 88 While at the CDC, D.A. became enamored with the field of epidemiology, which is tasked with public health in general and sleuthing out the cause and spread of disease in particular. He earned a master of public health from Johns Hopkins in 1960 before returning from Baltimore to CDC’s headquarters in Atlanta, Georgia. There he worked with another Johns Hopkins alumnus and expert epidemiologist, Alexander D. Langmuir. Together, Langmuir and Henderson developed a plan that built upon ongoing experiences in South America. Specifically, the CDC had been working in partnership with the Pan American Health Organization (PAHO) since 1950 to eliminate smallpox in Latin American nations. By 1960, the last reported cases of smallpox were recorded in Bolivia, Chile, French Guiana, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela (within six years, Colombia, Ecuador, and Argentina would join the list of smallpox-free nations). By 1965, Henderson and Langmuir also set their sights on eliminating smallpox in west and central Africa, and they gained support from the U.S. Agency for International Development (USAID) to do so. Within the year, Candau demanded Henderson be given responsibility (and blame) for the impending WHO program.
Building upon the demonstrated successes of the Balmis Expedition, CDC, and PAHO programs, Henderson and the WHO targeted South America, which was a slightly ironic choice given the devastation wrought upon the natives of that continent in the post-Columbian era. The WHO initiated the Intensified Programme in 1967, focusing largely on Brazil, which documented the vast majority of smallpox cases in the Western Hemisphere.89 By 1971, the number of reported cases of smallpox in South America had shrunk from a peak of ten thousand cases per year in 1962 (even with PAHO participation) to nineteen in 1971, all of which were in Brazil. No natural infection with smallpox has been observed since that landmark year.
In parallel with the success in South America, the smallpox eradication program spread like wildfire (or a virus) through Africa and Asia. Indonesia was the first Asian country targeted, starting in June 1968, and the last case was recorded on January 23, 1972.90 South Asia followed, as did west, south, and east Africa, more or less in that order. This geographic trend also reflected the fact that under Henderson, an effort had already begun in Africa under the auspices of USAID. The eradication of smallpox by USAID was not only a laudable humanitarian goal but it also helped to serve the need to enhance friendship and cooperation, with the goal of wooing a restive region away from pro-Soviet regimes in Congo or Angola. Henderson’s leadership in eradicating smallpox while at the helm of the WHO program was made possible by a grand coalition of public health, scientific, and political muscle, which also facilitated the training of armies of vaccinators. Rather than immunizing every person on the planet, vaccinators were efficiently dispatched to hot spots of infection. These individuals practiced the strategy of “ring vaccination” by vaccinating and evaluating individuals near an infected patient.
Immunizing the peoples of east Africa proved to be the most problematic, due to endemic warfare among the Ethiopians, Somalis, and various tribal antipathies, and because a nomadic culture, which runs contrary to the idea of ring immunization, has predominated for millennia in this corner of the world. As a result of a Herculean effort involving dedicated volunteers and unprecedented domestic and international cooperation (every nation of the world), the last case of naturally acquired smallpox was documented in Somalia on October 26, 1977, almost ten years to the day after Henderson was appointed the head of an enterprise that was, according to the Director-General of WHO, doomed to fail.
The final victim, Ali Maow Maalin, ironically worked as a cook and laborer in a Somali hospital in the southern city of Merca, southwest of the Somali capital of Mogadishu.91 The cook was presumed to have been vaccinated (there were conflicting reports at the time) but later admitted, in a 2006 interview with the Boston Globe, that he avoided being immunized because “it looked like the shot hurt.”92 Maalin had been exposed to the disease because of a series of unfortunate events. Two months prior, a handful of children in a nomadic tribe began to display the classic symptoms of smallpox: fever, malaise, headache, back pain, and the later eruption of flat, red spots on the face, hands, and arms, later followed by the trunk and legs. The wanderers made their way to an encampment at Kurtunawarey, where the symptoms were reported to a WHO team about sixty miles away in Merca. On October 12 the family was cautiously escorted by immunized WHO officials from Kurtunawarey to an isolation camp that was carefully controlled to avoid spreading the disease. In addition, WHO officials isolated the encampment and anyone who had come into contact with the nomads. Maalin, supposedly protected, was dispatched in a Land Cruiser to gather the sickened from the isolation camp for transfer to the Merca hospital, a trip that lasted as little as five minutes.93 Sadly, one of the children, a six-year-old girl by the name of Habiba Nur Ali, perished from the disease and was the last to die from naturally occurring smallpox. The WHO officials carefully isolated and monitored all susceptible people who had come into contact with the infected children. However, these same officials remained unaware that Maalin had not been immunized.
The conclusion of the disease unfolded like a Hollywood thriller. On October 22, Ali Maalin displayed a fever and headache and was treated for malaria, which is endemic in the region. The symptoms persisted, and the doctors treated Ali for chicken pox before releasing him from the hospital. Over the next few days, it became obvious that smallpox, not chicken pox, was the culprit responsible for his symptoms. Maalin, fearing isolation, fled. Officials began a manhunt that ranged more than seven hundred square miles, both to isolate Ali and immunize all individuals who came into contact with him. More than ninety people had direct contact with Ali during his flight from the hospital, but through masterful detective work, each was tracked down and quarantined. The runaway himself was sought using, among other things, a reward of two hundred Somali shillings (about forty US dollars), an amount of remuneration sufficient to entice one of his coworkers to turn him in. For the next six weeks, officials isolated 161 people who might have come into contact with Maalin. Collectively, they held their breath. More than 54,000 people in the immediate locale were vaccinated in a final push to ensure that the disease would spread no further. Ali Maalin survived with minimal complications. Over the following four months, WHO officials and volunteers initiated a door-to-door campaign to seek any other cases of smallpox, an action that was gradually expanded to include most of Somalia. On April 17, 1978, regional officials in Nairobi, Kenya, sent a telegram to the Geneva headquarters of WHO saying, “Search complete. No cases discovered. Ali Maow Maalin is the world’s last known smallpox case.”94
Although Maalin had been a source of considerable consternation for the WHO staff in Somalia, his later good works redeemed him in the latter months of 1977. Again reminiscent of a Hollywood film, he remained in Merca and volunteered for a later WHO immunization campaign to eradicate poliomyelitis, avowing that, “I’m the last smallpox case in the world. I want to help ensure my country will not be last in stopping polio.” Empathizing with the local villagers’ fear of immunization and relating his
own past fears with smallpox vaccination, Ali Maow Maalin could draw upon his experience and educate his countrymen as to the benefits of polio immunization. His audiences included some of the most nefarious, best-armed and skeptical people in the world, including an ever-changing variety of warlords, terrorists, and militias. Yet because of the efforts of Ali and other WHO officials and volunteers, Somalia was declared free of polio in 2007. In the spring of 2013, polio returned to Somalia (from an unknown source), and Ali immediately rose in response. In a region with seemingly endless conflict, most recently propagated by the Al Shabaab militant Islamist organization, the public health system was close to shattering. Nonetheless, the last smallpox survivor returned to his personal war against polio. However, the regional killers, large and small, were not limited to terrorists, smallpox, or even polio. Rather, on a hot summer day in mid-July 2013, Ali Maow Maalin began again to display signs of fatigue, headaches and fever. Dedicated to his polio vaccination campaign, he delayed seeking medical health but ended up in the hospital, where he was again, and this time accurately, diagnosed with malaria. Unfortunately, the 58-year-old husband and father of three was unable to overcome a different and still elusive microbial adversary inside him, and he died of malaria on July 22, 2013.95
A taut Hollywood plotline might have ended with Ali Maow Maalin, but the story took an unexpected turn in 1978. On August 11 of that same year, four months after the triumphant telegram declaring Ali Maow Maalin to be the last case of smallpox, an Englishwoman by the name of Janet Parker complained of a migraine headache and intense spasms of muscle pain.96, 97, 98 Janet was a forty-year-old professional photographer, who had formerly served as a forensic photographer for the West Midlands police and was now employed by the University of Birmingham. Brushing off the symptoms as the early signs of a simple cold, she continued working until noting a rash, which led her to seek medical attention. Nine days after her first symptoms, Janet was admitted on the late morning of August 20 to the East Birmingham Hospital (now known as Heartlands Hospital) with complaints of an unremitting headache. Her ending up in this particular hospital was fortuitous, as Dr. Thomas Henry Flewett, consultant virologist to the West Midlands NHS Trust hospital, was a leading authority on smallpox diagnosis using electron microscopy. This relatively new technology provided ultrahigh resolutions to detect some of the world’s smallest pathogens, such as viruses.99 Within a few hours, Flewett and his colleague Alasdair Geedes, himself an expert in bacterial infections, were dumbfounded to diagnose Janet Parker with a rampant case of smallpox.100 Later that evening and in recognition of the lack of adequate containment facilities at the East Birmingham medical facility, Janet was transported by secure ambulance to the Catherine-de-Barnes Isolation Hospital in Solihull, which had been recently abandoned but was quickly revitalized to accept an unexpected entourage.
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