In Atlanta and Moscow, within stainless steel freezers deep in the bowels of the Centers for Disease Control and Prevention and the Moscow Research Institute for Viral Preparation's High Containment Laboratories, is confined the greatest serial killer in the history of mankind. Smallpox, eradicated as a naturally occurring disease in 1977, waits in 500 vials for the determination of its final fate. The exact origins of smallpox are lost in the mists of pre-recorded history. Most disease historians point to the Indus Valley of India as the place where smallpox made its first appearance. The oldest known case for which proof exists was that of the Egyptian pharaoh Ramses V who died in 1160 BC and on whose mummified remains the classic lesions of smallpox can still be seen. The last naturally occurring case was a young Somali hospital cook who contracted the disease in October 1977. Between pharaoh and cook, smallpox was responsible for the deaths of millions and reshaped currents of history. It was overcome by a ten year campaign that combined all the elements of a military undertaking. The Enemy Smallpox's scientific name is variola. Variola major was the only form of smallpox recognized until the Nineteenth Century when a milder strain, variola minor, appeared recognized in southern Africa and the West Indies. This strain later spread to Brazil, North America and parts of Europe. The disease caused by variola minor and its spread was exactly like variola major. But whereas variola major killed 25% of its victims, variola minor killed only 1 percent or less. Variola minor also scarred its victims less frequently (7% vs 75% for variola major). In 1965 Henry Bedson, the eminent British virologists, identified a third strain, variola intermedius, in samples isolated from East and West Africa. All three forms bred true and an attack by one conferred immunity against the others. Variola major predominated until just before the disease was eradicated. Smallpox's onset was deceptively ordinary. About two weeks after infection, usually by inhaling the virus on airborne droplets, a victim developed a fever and splitting headache, often accompanied by a backache, chills and vomiting. Two or three days later, as these symptoms began to fade, the first sign of the rash appeared, starting on the tongue and palate and spreading rapidly on to the forehead and face and then to the limbs and the trunk. The spots filled with fluid, growing and hardening. The result was painfully disfiguring with swollen pustules sometimes so severe that they forced the victim's eyelids shut. At this point -- 10 to 16 days after onset, death was most likely to occur. In the past it was known that if the sores did not touch (discrete smallpox) mortality was less than 10%, if they ran into each other to form huge pustules, mortality was 50 % (confluent smallpox). If bleeding erupted beneath the surface of the skin, and from the nose and mouth (hemorrhagic smallpox, purpura variolosa, black smallpox) death was certain. If the patient survived this stage there was a gradual subsidence of the symptoms, with scabbing and healing. Frequently it left the victim branded with pockmarks for life. The Romans The impact smallpox had on history cannot be overestimated. Its first likely appearance in Europe was the Antonine Plague of 165-66 AD, when the legions of Avidius Cassius were decimated by the disease after a successful campaign against the Parthians. The returning survivors spread the disease throughout the Empire. In Rome, one third of the inhabitants died. Roman forces on the Danube frontier were thrown into disarray. Severely weakened, they were unable to stem the invading barbarians who overran Noricum, Pannonia and Aquileia at the head of the Adriatic Sea. The Emperor Marcus Aurelius, unable to raise troops from the depopulated citizenry, drafted slaves and gladiators into the legions. When that proved insufficient he auctioned off the imperial household, then hired mercenaries from Germanic tribes and the Scythians to defend the Empire. The epidemic depopulated the Roman Empire. A century later, just as Rome was beginning to regain the demographic stability necessary to recover, smallpox returned. Eusebius records that in Alexandria, the second city of the Empire, the number of men aged 14 through 70 years of age after the plague equalled the number of those aged 40-70 before it struck. Throughout the Empire the population base dwindled further. The Romans were unable to field the large armies of the past. The number of legions fell. The Empire found itself increasingly defenseless. Less than fifty years later, Constantine moved the imperial capital to Constantinople, essentially abandoning the West to the barbarian tribes pressing on it from northern Europe. The Western Empire disappeared with a whimper. More Victims In 754 the caliph Abu-al Abbas, who had overthrown the Ummaiyad dynasty five years earlier and laid the foundations for the Abassid dynasty, was struck down by smallpox while still in his early thirties. Smallpox killed Chinese Emperors, African tribal chiefs, European monarches and Arab emirs, and millions of unknown, unnamed people. Its greatest days of devastation were in the aftermath of the European discovery of the New World. The New World In November 1519 Hernando Cortes and his followers reached the Aztec capital of Tenochtitlan. At about the same time smallpox was introduced onto the mainland of the New World by an African slave named Francisico de Baguia. In the ensuing months smallpox spread throughout the Aztec empire, as Montezuma feted the Spaniards. By the summer of 1520, smallpox had reached the edge of Mexico's inland plateau. In September it reached the towns around the lakes in the Valley of Mexico. Then in October, Montezuma was killed by his own people, and the Aztecs, under the leadership of Montezuma's aggressive brother Cuitlahuac drove the Spaniards out of the city. In the wake of Cortes' retreat, smallpox entered the Aztec capital. The Aztecs called it hueyzahuatl, "the great leprosy," because its victims were so covered with pustules that they looked like lepers. In its spread through the countryside the disease exerted a devastating impact on the populace who had no resistance to it whatsoever. Tribute lists indicate the population of the Aztec Empire was 30 million in 1518. By 1568, Spanish officials estimated only 3 million remained. By 1620 the number had shrunk further to 1.6 million. No one knows how many truly died from smallpox and the other diseases that followed in its wake. The native Americans simply called it the "Great Dying." Whatever the actual number of the dead smallpox was a catastrophe and of a scale far exceeding its earlier rampages on Hispaniola, Puerto Rico and Cuba. A Spanish friar, Fray Toribio Motolinia described the epidemic and its effect in graphic terms: " ...when the smallpox began to attack the Indians it became so great a pestilence among them throughout the land that in most provinces more than half the population died. For as the Indians did not know the remedy for the disease... they died in heaps, like bedbugs." In Tenochitlan the disease raged for sixty days, killing by the cartload. One of its first victims was the new Emperor Cuitlahuac who had ruled Mexico for a total of four months. Two months later Cortes returned and took the great city amidst a raging smallpox epidemic that left so many dead he was forced to abandon his conquest for sixty days until the natural decomposition of the enormous numbers of dead had rendered the city fit to live in again. The role of smallpox in the New World was far from over. From Mexico the disease spread south and north cutting a swath of destruction before it. It reached modern day Peru and took the life of the great Inca leader Huayna Chupauc, who had doubled the size of the Empire. The designated heir, Ninan Cuyoche, was dead by the time word of Huayna Chupuac's demise was brought to the Inca capital at Tumipampa. Huayna Chupuac's general Minacnacatamayta and several other officers also died. A war of succession broke out in the Inca Empire when Huascar was appointed Inca, then challenged by his illegitimate brother Atahualpa. A disastrous civil war broke out, lasting five years. Smallpox moved with the army and the civilians to spread thoughout he empire and materially aid the Spanish conquest. The Inca Empire suffered a similar mortality as incomprehensible in its completeness as suffered by the Aztecs. Cieza de Leon, a Spanish chronicler wrote with simple eloquence of the sudden, awful emptiness in the land. "No testimony remains that the country had once been populated other than the great cemeteries... They asked Benalcazar how many Indians he found between Quito and Cartago, and they desired to know from me how many remain. Well, there are none. In a town that had a population of 10,000, there was not one person left." Visitations of the disease in North America were no less devastating. In 1617-1619 smallpox wiped out nine-tenths of the Indian population along the Massachusetts coast. The epidemic fortuitously cleared a place for the first Pilgrims. Seven years earlier, the Narragansetts alone were said to be able to muster 3000 warriors, whereas Miles Standish and his companions found only a few straggling inhabitants, innumerable burial places, empty wigwams and some skeletons when they arrived at Plymouth in 1620. Surveying the aftermath Standish was frank in his appraisal "Smallpox was the blessing in disguise that gave (us) an opportunity to found the State." Not only the natives suffered. In 1776 the American colonial army was driven from Montreal and hence, lost Quebec and all of Canada. The British army, outnumbered two to one, were variolated, the Americans were not and came down with smallpox. The epidemic that swept through the troops nearly wrecked the colonial cause. In Europe smallpox wreaked havoc not only with the common man but with crowned heads as well. In 1712, the 70 year old Louis XIV, France's Le Roi del Soleil looked upon his son, grandson and great grandson and commented that in the history of France, the succession had never been so secure. The Sun King tempted fate. Within eleven months all three were dead, having been Grand Dauphins of France and victims of smallpox one after another. In the process Bourbon claims to the Spanish throne were lost forever. The sole male heir that survived -- another great grandson -- was whisked away from Versailles by concerned servants and spared the ravages of disease. For Louis XV this rescue was merely a stay of execution. In 1774, after a reign of fifty years, another smallpox epidemic broke out in Versailles. Mistakenly believing that he had had the disease as an infant during the epidemic that had killed his brother, Louis refused to leave. Smallpox struck him down. His last words were "apres moi l'deluge," ("after me, the deluge"). Fifteen years later French resentment against the House of Bourbon smoldered into the Revolution. Defense Protection from smallpox was, at first, limited to appeals to the supernatural. In ancient Asia and Africa there were gods and goddesses you could pray to. In India, Shitala Mata (left) was the Hindu goddess of smallpox, while the Chinese recognized T'ou-Shen Niang-Niang (right) as the disease's deity. Saint Nicaise, (beginning of article) a bishop of Rheims who recovered from the pox (only to be killed by the Huns in 452) was adopted by the Church as its patron of pox victims. Folk tradition held that smallpox victims could be helped by the color red ("erythrotherapy")-- a belief that resulted in some of the most curious treatments in the annals of medicine. Sufferers were dressed in red, bathed in red light and plied with red food and drink. No one has ever satisfactorily explained why the belief developed, but it died hard. Three clinical trials were conducted at the start of this century and among its adherents was a Nobel Prize winner, the dermatologist Niels Finsen. Intelligence Gathering The first important step towards eventual control occurred in 895 when Abu Bakr Muhammad ibn Zakariya ar-Razi (Rhazes), the great Persian-born Arab physician published A Treatise on the Small-pox and Measles. The work was the first to distinguish the clinical symptoms of smallpox from measles. Ar-Razi also described the seasonal variation of smallpox epidemics, although he misunderstood the cause of the disease, attributing it to the need of children's blood to ferment. Two generations later, Haly Abbas (d. 994) noted that proximity to previous victims seemed to be one of the causes of the disease, thus suggesting the idea of contagion. Both men's work were translated into Latin and authoritatively influenced the treatment and recognition of smallpox for centuries. Perimeter Defense The first demonstrably effective preventive against smallpox was a process called variolation. By the Thirteenth Century the Egyptians had learned that if you rubbed fluid from a smallpox pustule into a scratch on an uninfected person he or she would develop a mild, nondisfiguring case of the disease and thereafter be immune. It is doubtful that the Egyptians invented the technique. Tribes in central Africa, Asia and China were found to be using the practice during the smallpox eradication campaign and it appears to have independently developed there. The practice eventually spread throughout the Islamic world to Turkey, where Lady Mary Wortley Montague, the wife of the English ambassador to the Ottoman Caliph, learned of it in the early 1700s. She introduced it to England by having her four year daughter successfully inoculated with it in 1711. With the proof that variolation could protect you from the worst ravages of smallpox, the process gained immensely in popularity. "To take the smallpox" was a carefully planned social event for many people. John Hancock's wife was bitterly disappointed at Martha Washington's decision to decline her "gracious invitation" and take variolation elsewhere. Variolation was also put to military use. As mentioned above the British forces sent to the New World, the Americans, until the loss of Montreal drove the lesson home, were not. Washington finally received approval to variolate his troops in the spring of 1777. While variolation could provide protection and prevent the terrible disfigurement a naturally occurring case of the disease almost inevitably caused in the Eighteenth Century, it was not without its drawbacks. You had to stay in quarantine while your mild induced smallpox ran its course, because you could give a full blown case of the disease to someone else. At the same time it was possible that you could die if you were inoculated with a particularly virulent strain. Still it was the best available remedy. And when one considers that the chances of dying from smallpox were as about 1 in 4 for naturally occurring smallpox as opposed to 1 in 100 from variolation, its popularity becomes self-evident. Variolation was introduced into Europe just as smallpox was undergoing a resurgence and increase in virulence. One contemporary account described the situation: "When smallpox is epidemic, entire villages are depopulated, markets ruined and the face of distress spread over the whole country." In areas of central Europe in the Eighteenth Century a new born baby was not given a name until after he or she had experienced smallpox and survived. Hence the European medical profession greeted variolation with relief. It would also point to another alternative. Defense in Depth Since the time of William Shakespeare, milk maids in England had been noted for their complexions and their beauty. In 1792 Edward Jenner (1749-1822), a Gloucestershire physician discovered, while trying to variolate his patients, that some of them were immune despite never having had smallpox. "These patients," he later wrote, "had undergone a disease they called the Cow Pox, contracted by milking cows with a peculiar eruption on their teats." Jenner also noted that "a vague opinion prevailed that it was a preventive of Small Pox." Jenner was no simple country doctor. He was a careful natural scientist by 18th (or 20th) Century standards. He was the first to associate angina pectoris with changes in the coronary arteries seen at autopsies. He devised a method for purifying tartar emetic by re-crystallization. He was elected a member of the Royal Society because of his description of the unusual behavior and adaptation of the cuckoo, which lays its eggs in the nests of other birds, and whose young then use transient depressions on their backs to expel the rightful tenants, hatched or unhatched. In 1796 Jenner took material from a cowpox sore on the hand of the milkmaid Sarah Nelmes and inoculated a young boy, James Phipps with it. On July 1, 1796 he inoculated the boy with smallpox, but it failed to take -- Phipps was immune to smallpox. J enner wrote up his observations and submitted them to the Royal Society in 1797. The paper was quietly returned with a note that if he valued his reputation -- already established by his paper on the cuckoo -- he had better not promulgate such ideas as the use of cowpox for the prevention of smallpox. (Rosen 1958) Undaunted, Jenner took advantage of a cowpox outbreak in the spring of 1798 to inoculate five other children and later challenge them with smallpox. When they also failed to develop the disease, he published, at his own expense, a small pamphlet recounting his experiments entitled An Inquiry into the Causes and Effects of Variolae Vaccinae, a Disease, Discovered in some of the Western Counties of England, particularly Gloucestershire, and known by the name of Cow Pox. It was, "as if an Angel's trumpet had sounded over the earth." Jenner's discovery was universally hailed. The Empress Dowager of Russia ordered that the first child vaccinated be named Vacinoff and given an imperial pension for life. She also sent Jenner a diamond ring. The king of Spain, underwrote the Balmis-Salvany Expedition, certainly the most dramatic effort to promote vaccination in his dominions in North and South America and Asia. A living chain of orphan boys, vaccinated in succession during the voyages, brought Jenner's vaccine to the Spanish colonies. The Duke of York ordered the vaccination of British troops in 1802. Napoleon followed suit shortly afterwards. Keenly interested in military medicine, he had followed Jenner's discovery with enthusiasm. When Jenner wrote the French emperor an appeal, asking for the release of certain English prisoners of war, Napoleon declared "Ah Jenner, I can not refuse Jenner anything!" (Ah Jenner, je ne puis rien refuser a Jenner!) As the effect of Jenner's vaccine was realized, the possibility of smallpox eradication was first broached. In 1801 Jenner wrote that "it now becomes too manifest to admit of controversy that the annihilation of Smallpox, the most dreadful scourge of the human species, must be the result of this practice (vaccination)." Thomas Jefferson was also of the same mind. "Future generations will know by history only that loathsome smallpox has existed," he wrote to Jenner in 1806, "and by you has been exterpated." Still smallpox was nothing to be treated lightly. Particularly when armies gathered together. During the American Civil War preventing smallpox was a primary concern among the hastily assembled and woefully inadequate medical corps. Coming mostly from farms and small rural communities, the majority of the new soldiers had never before been with so many others in confined spaces. Relatively few had been exposed to the common communicable diseases -- measles, chickenpox, mumps or whooping cough. The results were predictable. They shared experiences and diseases in the cantonments. Most feared of the "recruit diseases" was smallpox. The disease could go through a regiment like a scythe. Smallpox occurred in 18,952 reported cases of whom 7,058 (37%), died. The overall problem of smallpox was much milder than would have been expected before Jenner. Army medical doctors looked upon smallpox as contagious (the only disease which they thought was) and placed cases in isolation. The entire 11th Michigan was placed under quarantine (nearly causing a mutiny) in December 1861 because of the rumor of one case in the unit. In addition new recruits were vaccinated as required by the Medical Corps. Vaccination against smallpox was conducted with the same disregard and lack of appreciation for sterile technique that characterized the surgical procedures of the era. A soldier from Massachusetts described a typical regimental vaccination: "Such a wholesale slashing and cutting never was witnessed before. The commanding officer of each company would march up his men, all with bared arms. The doctor would make three or four passes with a knife, cutting through the skin, and punch a little of the vaccinating matter into the wound." The American Civil War helped spur the concept of universal vaccination in the United States. Five years later, the Franco-Prussian War, and the smallpox epidemics that followed in its wake, would do the same for much of Europe. Franco-Prussian War France and Prussia declared war on each other in late July 1870. On September 2nd, Napoleon III surrendered to the Prussians at Sedan. However fighting continued elsewhere as French republicans proclaimed a new government in Paris. The French capital was besieged on September 19th, falling to the Prussians on January 28, 1871. At the war's start, vaccination was still entirely voluntary in France and northern Germany, but mandatory for infants in southern German states. With war the movement of peoples began and smallpox followed in its wake. The German army, unlike the civilian population, required vaccination of all troops and revaccination every seven years. Of the 800,000 man army a mere 8,643 caught smallpox and only 459 (5.4%) died. In France's one million man army, of whom 700,000 were taken prisoner, 125,000 men were infected and 23,470 (18.7%) died (Hopkins 1983, 90). Thus the French army lost nearly as many men to smallpox alone as the German army lost to all causes in the entire war. The French army was militarily unprepared for war, but smallpox could only have made matters worse. In one 1158 man Gardes mobiles unit, for example, over half the men developed smallpox during the war. The large number of French prisoners were a reservoir of smallpox. When 373,000 of them were moved to Germany for incarceration, they spread smallpox throughout Europe. Starting in fall of 1870 the disease spread rapidly to the German population, probably as a result of petty trade in personal effects, including the clothes of dead Frenchman. Whereas Prussia had recorded 4200 deaths from smallpox in 1870, 59,839 and 65,109 were recorded in 1871 and 1872. Throughout all of Germany at least 162,000 died from the disease. Only a small number of deaths in the southern states where vaccination was mandatory. The French, with no compulsory vaccination suffered as severely as Prussia. The Franco-Prussian war triggered a five year smallpox epidemic throughout Europe that claimed 500,000 lives. The pandemic discriminated sharply between civilian populations of nations with compulsory vaccination laws for civilians such as England, Scotland, Sweden and Bavaria and states without such laws as Prussia, Austria and Belgium. The latter had smallpox mortality rates about three times higher than the former, and young children comprised most of the death in states where vaccination was not required. In addition the value of revaccination was illustrated by the Prussian army's epidemiologic experience during the war. Although this wave of epidemics was not anywhere near as severe as those Europe had suffered in the Eighteenth Century, it was by far the worst catastrophe of the Nineteenth. It shocked Europeans out of their complacency about controlling smallpox and provided a costly lesson in public health policy. Direct legal actions were taken in England and Germany to strengthen existing vaccination laws, but nothing was done in either France or Austria. These two countries continued to suffer a higher rate of smallpox mortality than any other European country except Russia. Pushing the Enemy Back Slowly, inexorably, smallpox was beaten back as a result of vaccination and the effects of herd immunity. New cases and mortality decreased throughout the 1800s and into this century. As a result of systematic vaccination smallpox vanished from England by 1940, from the United States by 1950, from China by 1965. By the mid-1960s the World Health Organization, announced an ambitious plan to fulfill Jefferson's promise to Jenner that "future generations will know by history only that loathsome smallpox has existed." In theory smallpox eradication was practical. The symptoms of smallpox were obvious and needed no confirmatory laboratory tests. Furthermore, anyone contracting smallpox developed the disease. There simply was no carrier state, and there were no asymptomatic infections. Transmission was from person to person so there were no vectors or intermediate hosts to contend with. Man was the only known reservoir, hence the virus had no animal reservoir to retreat to. Patients were only infectious in the four days prior to onset, allowing for rapid tracking. Long term, if not lifetime, immunity followed vaccination or natural infection. The virus could not survive outside the human body. And finally, alone among the anti-viral vaccines, smallpox did not use the actual variola virus or any of its components -- there was not the slightest chance of a vaccine related case. Materiel The first problem confronting Henderson and the eradicators was the vaccine itself. A great deal of progress had been made since Jenner's first experiment. Arm to arm vaccination was no longer the approved method. The vaccine in use at the start of the campaign was fairly stable. Though ideally it should be refrigerated, it could survive for one month if kept cool. Since it could be freeze-dried, transport was no problem. Once shaken in diluent of sterile water or saline, it was ready. The problem lay in its manufacture. There was no standardization among the various sources with regard to potency, stability and purity. Some samples of vaccine revealed no virus whatsoever. Under Henderson's prodding, cajoling and outright demanding, all the participants in the program agreed to submit samples of their vaccine to either a laboratory in the Netherlands or one in England for quality control. The device to deliver it was equally effective -- the traditional scratching fork was displaced by a rapid-fire jet- gun, which in turn gave way to the bifurcated needle that delivered just one drop and needed neither repair nor maintenance. Strategy When local and regional smallpox eradication programs had begun in 1959, the strategy had called for mass vaccination campaigns designed to reach 80% of the population. This proved unsatisfactory and in 1964 WHO called for 100% coverage (Henderson, 1980). The one bit of good news was that the eradication effort was proving that immunity provided by high quality vaccine was surprising durable, and that boosters, originally thought essential, were unnecessary. However even with this discovery, 100% vaccination seemed unachievable. There simply was neither enough vaccine nor enough field workers to blanket the planet. Tactics Then in 1968, William Foege, director of the Western and Central Africa eradication effort, ran short of vaccine. He abandoned the concept of 100% coverage in favor of another strategy based on rapid surveillance. When word of a case or an outbreak was received, Foege targeted the outbreak village and those surrounding it for intensive containment vaccination. The new strategy essentially isolated the existing smallpox cases behind a wall of immune individuals. Transmission was interrupted and the outbreak died out within the containment area. Smallpox could be eradicated -- even when the overall population was less than 50%. Foege's discovery meant that detection and containment of outbreaks was not of equal, but of greater priority, than mass vaccination. Henderson ordered a shift in emphasis. The primary strategy was the rapid detection and containment of each outbreak. Since smallpox must spread from person to person in a continuing chain of infection, the objective of the strategy was to isolate each of the chains by isolating the case and vaccinating the contacts. Military theoreticians call this approach either "divide and conquer" or "defeating the enemy in detail." The elegance of the strategy was that if surveillance was maintained at a high level, smallpox could be defeated with much less effort than initially thought necessary. The Final Assault One by one countries fell to the vaccine. Like a cornered animal, smallpox fell back into oldest reservoirs. Smallpox made its last stands in Bangladesh, Somalia and Ethiopia, politically volatile countries teetering on the verge of chaos. In Bangladesh there was a presidential assassination. As the campaign drew to a climax, Somalia invaded the Ethiopian lowlands. At one point a helicopter with a vaccination team was held for ransom by a band of Somali rebels. While negotiation went on, the team vaccinated their captors. The assault was inexorable and remorseless. Variola major was the first to fall. In early 1975, Rahima Banu, a three year old girl living in Bhola Island, Bangladesh developed smallpox. An intensive containment campaign was organized. She was the last case of smallpox's most virulent form. From Asia, the attackers moved to the Horn of Africa. Smallpox was pushed to the brink of eradication. On October 26, 1977, ten months after WHO's self-imposed ten year deadline, a twenty-two year old hospital cook named Ali Maow Maalin developed a case of smallpox he had contracted from two men, both smallpox victims, he was helping to a nearby hospital. On November 19, he recovered from a relatively mild case of variola minor. Maalin's illness was the last occurrence of smallpox from a natural infection. EVER. One Last Gasp As the months passed by without any cases reported from anywhere, despite a planet-wide search and a $1000 reward, belief in the eradication of smallpox went from a high degree of confidence to virtual certainty. The Global Commission for the Certification of Smallpox Eradication was in the process of gathering the necessary documentation when smallpox made its last stand. Janet Parker, a medical photographer in the anatomy department at the University of Birmingham medical school developed a fever on August 11th and a rash on August 15th. By September 11th she was dead. Her case was traced back to a smallpox laboratory in the same building as her studio and darkroom. Investigators concluded that the most likely cause was escape of the virus into the air, from the lab where it was kept. It is believed to have then drifted through the ventilation system into Parker's darkroom on the floor above. Parker's father suffered a fatal heart attack while visiting her and her seventy year old mother came down with a mild case from which she recovered. Eight days after Parker's case was confirmed, Henry Bedson, the prominent virologist who had discovered variola intermedius and the laboratory's director, committed suicide. There were no other cases. On December 9, 1979, the members of the Global Commission for the Certification of Smallpox Eradication signed a simple document attesting that smallpox had been eradicated from the face of the earth. It was the single most historic public health document ever written. For the first, and only time, mankind had, by his own efforts, freed himself from the scourge of a disease. Loose Ends The eradication of smallpox was an unprecedented, perhaps unrepeatable accomplishment. But as in all successful wars unforeseen questions confronted the victors. The battle against smallpox was won, but like prisoners of war, remnants of the once formidable viral armies remained, held in various laboratories throughout the world. The Birmingham episode galvanized opinion among world public health officials -- the real danger from smallpox no longer lays in nature, but in these stocks of variola virus still remaining in laboratories. Throughout the late 70s and early 80s WHO encouraged labs still harboring the virus to destroy their stocks of virus or ship them to either the CDC in Atlanta or the Research Institute of Viral Preparation in Moscow. Japan shipped its stock in 1978. In 1981 the last variola virus in the Netherlands was whisked, complete with motorcycle escort, to a plane for shipment to Atlanta. England followed suit in 1982. In 1983, South Africa, the last holdout, destroyed its virus amid a flurry of publicity. The Birmingham episode still weighed heavy on the minds of many. Despite its confinement, smallpox is still lethal. A small error could introduce it into an unvaccinated population with unforeseeable results. While vaccine could be produced in mass quantities in short order, deaths in the dozens, hundreds or thousands would be the inevitable result of an escape. What kept smallpox confined, rather than eliminated, all these years was an understandable reluctance to destroy what are the last remnants of a life form. Then in the late 1980's it became possible to map the entire virus' genome and to sequence the order of its 175,000 base pairs -- in effect creating a genetic blue print. With this advance the last remaining objection to eliminating variola vanished. The specter of the possibility of these remaining stocks escaping into the increasingly unvaccinated population of the world led WHO, the US and the former USSR, in December 1990, to decide that all remaining variola viruses would be destroyed. WHO also suggested some further precautions. All laboratories that have ever experimented with the virus are being asked to search the contents of their freezers to make sure no overlooked vials remained tucked away in out of the way corners. In Fall 1993 another meeting was held. Opinion in the world scientific community was bitterly divided between those in favor of destroying the remants and those for whom this is too final an act. Opponents of elimination question the wisdom of destroying another life form. Their arguments are based on philosophical and ethical considerations and a deep concern that the irrevocability of the act has not been thought through. Possible dangers are dismissed as hysterical -- smallpox virus has been safely confined for nearly a generation without an accident. There is no rush. On the opposite side are those who point to other facts. The smallpox virus, they argue, has no function beyond mere existence. No vaccine is derived from it. Variola's genetic structure has been mapped and sequenced. If necessary it could, with current technology, be recreated by any one in possession of the full blueprint. What smallpox is, they argue, is a proven killer. This is one genie that has been put back in the bottle and its time to toss the bottle away. As of this writing the final answer, and the fate of smallpox, remain undecided. Back to Cry Havoc #5 Table of Contents Back to Cry Havoc List of Issues Back to MagWeb Master Magazine List © Copyright 1993 by David W. Tschanz. This article appears in MagWeb (Magazine Web) on the Internet World Wide Web. Other military history articles and gaming articles are available at http://www.magweb.com