Forgetting Smallpox

[box]Oscar To explores how the development of smallpox vaccination led to one of mankind’s greatest victories [/box]

As medical students, we may often find that medicine is simply a field to be learnt, where discoveries are to be made by far away researchers holed up in their labs. We are not exposed to the challenges that were once faced generations ago when the frontiers of medicine were being pushed by every practitioner. We should explore these many lessons learnt in the face of uncertainty and adversity should be remembered in order to ensure future successes.

One heroic advance was eradication of smallpox in 1979; this deadly disease is no longer something we need to fear. However, it would be mistaken to think it a simple process. Indeed, it took almost two centuries since the discovery of vaccination to finally eradicate smallpox. This was not through lack of want; children would not be counted by families until they had survived an infection. In the 20th century alone smallpox killed at least triple the casualties of both world wars combined.

The first key discovery for preventing smallpox was variolation; a method that exposed a person to small amounts of infective material to generate a light infection. Whilst still dangerous, this process gave significantly lower mortality. This process spread mainly among the rich who could afford it, leaving the poor to continue to suffering their burden. This stark inequality led to the first fever hospital made for the purpose of treating the infectious ill and offering variolation for free. Hospitals were of course built to allow the rich to show their patronage, but this gesture enabled people to receive treatment for the first time.

In 1796, a country doctor would discover a way to completely prevent smallpox: Edward Jenner had developed vaccination. This discovery of vaccination is now hailed as a key breakthrough but it was not always so; Jenner faced opposition from both the medical and religious groups. Religious generated a vitriolic scare similar to Wakefield’s modern MMR scare with images of people transforming into cows. Notably, whilst this caused problems with public perception, the scientific community seems to have ignored most of the issues raised; a trend it continues to this day. The ability of the scientific community to respond to controversy seems to have changed little in the space of two centuries.

Jenner’s problems with the medical community were different; prior to the discovery of viruses and immunity, he could not explain how vaccination worked. His scientific findings had errors as a result. However, his method was undoubtedly effective and it quickly spread all over Europe. Jenner became revered, but was always a humble country doctor at heart; indeed he almost bankrupted himself several times giving free vaccinations. However, this reverence also meant British doctors took his every word as truth, leading to disastrous consequences when Jenner claimed the protection was permanent when it in fact needed topping up. This stresses the importance of proper scientific assessment above the word of a prestigious professor: always cite a source.

Nonetheless, mass vaccination in Europe eventually led to the smallpox becoming locally controlled. Indeed, smallpox had to evolve into a milder strain in the USA to allow it to avoid eradication and spread back to the UK. However, success brought about bigger ideas: achieving global eradication.

Eradication almost never got properly underway; initial were efforts lacklustre with countries providing insignificant resources. The programme was almost abandoned until the USSR did something extraordinary. Having exiled itself from the WHO, the USSR returned, donating vaccines for use and an intensified programme to bring about eradication. These new efforts also lead to reflection by the WHO on why failures had occurred, some of which would seem shocking today.

One such finding was that the smallpox vaccine was not heat tolerant and became rapidly unusable in tropical climates. Further tests on batches also showed that doses were often insufficient. These were failings of quality control, a now integral part to the production of any of our medical supplies. In addition, vaccinators were trained in varying techniques, with inconsistent results. The development of the bifurcated needled simplified injections; even an illiterate person could easily learn the method, greatly improving delivery of vaccine.

Furthermore, considering the varying states of healthcare and infrastructure throughout the world, it would seem bizarre to impose strict uniform guidelines that were expected to be followed to the letter. The intensified programme instead used scientific method to the full, with volunteers encouraged to try what they could. Reports would be gathered and the best practice recommended throughout. These would vary from region to region due to the varying conditions and ensured adaption to the local environs.

The need for a great organization to oversee all this was paramount. The WHO would be able to undertake the necessary steps to ensure the surveillance of outbreaks and co-ordinate responses, allowing precision targeting of limited resources to the neediest areas. Other attempts to eradicate diseases such as Rinderpest failed until this was implicated. However, this required governments to be transparent; the programme was delayed when countries stopped WHO access and lied about outbreaks.

Smallpox left a legacy in extended programme for vaccination, aiming to eradicate other diseases such as Polio. However, these to date remain pipe goals, disappointingly for similar reasons that the initial smallpox programme failed; lack of funding, lack of organisation, lack of will. It seems history will repeat itself, until we take on the lessons we learned.

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