‘Smallpox -- The Death of a Disease,’ a Q&A with Dr. D.A. Henderson

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Smallpox was once a terrifying disease. It caused pain, panic, suffering and death to millions. Even when it did not kill, it could cause permanent pockmarks all over the face and in the mouth and, in many cases, blindness.

No surprise, then, that smallpox was feared all over the world. Some cultures created smallpox deities, then prayed for protection from the demigod of their own making.

In 1947, smallpox hit New York. A visitor from Mexico, who had become ill, died five days later. During his stay in a hotel, 3,000 people had booked rooms there; public health officials wanted to vaccinate all of them. Eventually, the city decided to vaccinate the entire urban population. Six million were vaccinated in four weeks.

Dr. D.A. Henderson led the World Health Organization’s campaign to success in eradicating smallpox. The last case occurred in October 1977. Smallpox is the only disease in history to have been deliberately, methodically eliminated.

Henderson’s new book, ‘Smallpox -- The Death of a Disease: The Inside Story of Eradicating a Worldwide Killer,’ takes us down the long road to eradication. From the time the idea was hatched that a living virus could be destroyed in the wild to the final patient, we go on the doctor’s journey all over the world as he battled bureaucracies, created public health reporting systems and figured out how to stop a killer.

Henderson talked about his journey and the book in an interview:

When you became chief of the smallpox eradication unit for the World Health Organization, you were only 38 years old, with 10 years of public health experience. How did you feel when you got the job? Was the weight of the world literally on your shoulders?

Well, I must say, it was a bit overwhelming, particularly taking over the duties at WHO. Most of the others were 15 years older at least. The [National Communicable Disease Center, when Henderson had worked] had very little experience operating a program like this, and in the branch we were in, we had none. We just sort of went from solving problem after problem after problem. If they had come all at once, then we’d have been done in. They kept appearing one after the other, and we just kept going.

What was your greatest challenge throughout the entire process?

There were a number of challenges. One of them was working through the bureaucracy. We had to get something done and there was this continuing kind of feeling that the WHO was a fairly staid organization. Trying to break out of that mold was very difficult.

At the same time we were beginning the global program, there was a feeling amongst scientists that you could not eradicate an organism. There was a view that organisms -- there’s an ecology they fit into in a kind of way that’s been around for years and years, and to eliminate them is impossible.

At the time, eradicating malaria was failing. So to take on a second eradication program and have that fail as well would reflect very badly on the World Health Organization.

Was there anything that you thought would be easy that proved more difficult than you expected?

I think the thing that was most startling was the problem of [the] vaccine. The Russians agreed they would provide 25 million doses a year. And they did. The U.S. would provide all the vaccinations to West Africa. Countries could not afford to do nothing and many countries were doing quite large programs. I thought: OK, vaccines won’t be a problem.

But one thing we tested was different vaccines from different countries and I think less than 10% of the vaccine met the standard. In some places, they were using a liquid and no virus.

All we could do was try to improve vaccine production in different countries.

You mention your former boss Dr. Alexander Langmuir, chief of the CDC’s epidemiology branch, and his introduction of the concept of disease surveillance as a key tool in disease prevention. He introduced this in the 1950s. How did disease surveillance help you in eradicating smallpox?

Up until the program began in 1967, they paid little attention to the number of people who actually had smallpox or who was vaccinated. You’d think countries would report all cases. They obviously weren’t.

They looked at the data they had coming in. In some cases, countries reported nothing at all. The data was so bad we couldn’t draw any conclusions. The idea of reporting regularly was a foreign idea. What we’d try to do is get health organizations to report every week.

At the time there was nothing like e-mail. There were few telephones. A lot of this was done by messenger. The idea was to get the data and vaccinate around where the cases were. The idea was to break the chain.

You dedicate a chapter to Africa and the challenges there. Can you talk about the continental specifics and which countries across the globe proved most difficult?

In terms of difficulties, the Democratic Republic of the Congo was a huge problem. They’d been through a civil war, and so by the time we were there, bridges were falling down. It is a huge country, and it was very difficult getting from place to place.

In terms of difficulty, I’d say the Congo. India is certainly up there. And Ethiopia.

What makes smallpox easier to eradicate than polio?

One thing is that we have to give just one vaccination and that will protect for at least 10 years. That vaccination [for smallpox] has been tested and it can last. With polio, you have to give a number of different shots, and you have to have refrigeration, otherwise it doesn’t last.

In certain countries, smallpox had deities that people worshiped. They knew and feared the disease. With polio, it was not that dramatic.

With smallpox, 3 out of 10 will die if left unvaccinated. With polio, 1 out of 200 affected will get paralysis.

Smallpox is very evident. It leaves extreme pockmarks on the face. Wherever we traveled, we always knew where it was. With polio, it can circulate silently.

Is smallpox back in Third World countries? Any chance of a resurgence?

No, I don’t think so at all. After the last case, we had teams going out not detecting any cases. They had to do this for three years. They searched villages over the world to see if there was smallpox there. That was a very effective way of checking it out. Of course, we knew there would be rumors. So they kept a rumor register, reporting cases and checking it out and making sure it was not smallpox. There were a number of cases reported as smallpox that were not.

Upon realizing you’d accomplished your goal, how did you feel about that?

One of the saddest days of my life was the day it was formally announced that smallpox had been eradicated. I thought, I’ve spent so much time with these people, trying to figure out how to solve these problems. It was not like being a tourist. Nothing like that. It was sleeping in some bad places and really getting to know the people and what they were thinking. I realized that day: I’m never going to be able to do this again.

Smallpox as a biological weapon -- let’s talk about that. How real is the possibility of that happening now?

It was very worrisome to us, especially when Ken Alibek defected from the Soviet Union and said they had a program to produce smallpox virus.

In the early 1990s, we learned they had a program with 60,000 people in 50 laboratories. We learned that this program was equivalent in size to their nuclear program. They had the capability to produce 50 to 100 tons of smallpox virus. They also had a larger research laboratory in western Siberia. When the economic collapse happened in the Soviet, the scientists scattered. It is a difficult thing to detect, what other countries are up to in terms of biological weapons.

Suppose smallpox was released, what would we do? Would you employ the same strategy you used before?

If it was released, we’d find the case and set up a hospital, then vaccinate the family and all contacts. If you had a case in Los Angeles or Washington, you’d have lots of people who would want to be vaccinated.

Our belief is that we’ve used this program before for major outbreaks in Africa, and it works well.

We have more than enough vaccine to cover everyone in the United States, if we had to. More than enough. We’re really prepared to move quickly.

The very idea that a life-threatening disease has been eliminated from the Earth is inspiring in many ways. What’s your vision for future successes like this? Do you think there’s any hope in HIV/AIDS prevention and eradication?

Yeah, I do. I think there’s a lot of hope. I think that we achieved what we did provides a lot of hope. Many different countries and cultures pulled together. We worked very closely with the Soviets during the worst days of the Cold War. We worked very well together.

We recruited a lot of young people in their 20s and 30s to come up with strategies for different countries and what would make sense there. There is a considerable number of young people who want to make a difference, and that is inspiring. William Gates has come forward and given a lot of money to come up with programs against tuberculosis, against malaria, against HIV. They have been very liberal with giving the money, and that has been inspiring to a lot of young people. This generation is better prepared to do things than we were.

-- Lori Kozlowski