Smallpox—The Death of a Disease: The Inside Story of Eradicating a Worldwide Killer By D. A. Henderson

Smallpox—The Death of a Disease, by D. A. Henderson (1), is a welcome addition to the bookshelves of infectious disease epidemiologists and historians interested in the complex interplay between infectious diseases and the human societies affected by them. While the book devotes a chapter to the disease and the virus that caused it, readers interested in a detailed account of the history of smallpox and the extraordinarily interesting cultural, religious, and social aspects of the disease in various regions of the world should probably turn to The Greatest Killer by Donald Hopkins (2) or at least begin with this earlier work. D. A. (having had the privilege of meeting and talking to Dr. Henderson on multiple occasions, I have, like several generations of infectious disease epidemiologists, come to know and refer to him simply as D. A.) has written a very different book, and it is a book that those interested in disease eradication and public health programs in general would do well to read in order to fully comprehend the importance of priorities, politics, and personalities in the success or failure of such efforts in the “real world.” Some of these very same lessons are, unfortunately, being relearned today as the world comes tantalizingly close to the eradication of poliomyelitis but thus far has been unable to add a second disease to the list of scourges from which humankind has been freed. For those not well-versed in the language of disease elimination and control, disease eradication has been defined as the reduction of the number of cases anywhere in the world to zero, without the need for ongoing control/prevention efforts (e.g., vaccination). Early unsuccessful efforts to eradicate yellow fever, malaria, and yaws, largely funded by the Rockefeller Foundation, had led to decades of skepticism about the feasibility of eradicating any disease; as a result, early proponents of smallpox eradication did not have an easy time convincing policy-makers, political leaders, and public health experts that smallpox eradication was feasible. D. A. recounts in some detail how the skeptics in Geneva (home of the World Health Organization) and elsewhere were eventually won over or, in some instances, replaced, marginalized, or simply ignored. An interesting and noteworthy side note was the critical role played by the former Soviet Union and the overarching intricacies of Cold War politics in the decision to move ahead with a smallpox eradication program. However, as D. A. and others soon realized, and as the lion's share of the book demonstrates in sometimes excruciating detail, deciding to eradicate a disease and actually eradicating it are two rather different things. The eradication program was plagued from the outset by a series of daunting challenges, any one of which might have doomed the effort, especially if those responsible for ensuring the success of the program had not been remarkably dedicated, adaptable, tenacious, and willing to question authority. Problems ranged from the inadequacy of funding and other resources to vaccine shortages and poorly made (and thus inactive) lots of vaccine to incompetence, cronyism, bureaucratic infighting, and virtually every other human shortcoming one can imagine (as expected, D. A. does not shy away from naming names and pointing out both the positive and negative attributes of those he encountered and worked with)—all of which played out against a backdrop of initially woefully inadequate disease surveillance, public health infrastructure, and vaccination delivery systems in the world's poorest countries. In retrospect, it is all the more remarkable that smallpox eradication was achieved. As D. A. explains, it was the combination of a heat-stable and inexpensive vaccine, a novel means of administrating it (i.e., the bifurcated needle), and an army of dedicated public health workers in numerous countries on several continents that made eradication a reality. However, eradication of smallpox was also made possible by the frailty of the virus. While the disease often blinded or disfigured those it didn't kill and was truly among the most fearsome of human maladies, the virus itself was genetically stable; it was not readily transmissible; and it did not produce asymptomatic infection. Furthermore, persons who were potentially infectious to others were almost invariably severely ill and bed-bound, meaning that intensified case detection and ring vaccination (i.e., vaccination of persons in the case's household and the neighboring community) could interrupt transmission. Eradication of wilier and more versatile microbial adversaries may prove far more difficult, although we are nearing the successful eradication of guinea worm (i.e., dracunculiasis) and are perhaps going to succeed in the eradication of polio in the next few years. Fittingly, the book concludes with chapters on the concern that smallpox might some day be intentionally unleashed on a highly susceptible and unsuspecting global population and the continuing debate about whether the last remaining vials of smallpox virus (currently stored in Atlanta and Moscow) should be consigned to the autoclave, as originally envisioned by the architects of the eradication program. D. A. lays out clearly the arguments made in favor of and against what was to have been the first intentional permanent extinction of a species from the face of the earth. As was the case with the smallpox eradication program itself, the decision as to whether or not to destroy the remaining stocks of smallpox virus is mired in the politics and nonscientific policy debates of the “real world”—one last source of frustration for those who labored so hard for so long to arrive at this juncture. The successful eradication of smallpox was, by many accounts, the single most important triumph of public health in human history, and many have argued that it would have been (indeed, would still be) entirely appropriate to award a Nobel Prize (either for medicine or for peace) to the individuals and organizations who made it a reality. The most notable value of this new book lies in its preservation for posterity of the details of the story behind this remarkable achievement. While some readers may conclude partway through the book that they don't need to know exactly who was helpful and who was not in each region and country where smallpox eradication activities occurred, the overall story that Smallpox—The Death of a Disease tells is one that everyone working in public health would do well to remember.