The Smallpox Vaccine

Yesterday’s post concerned smallpox, one of the most dreadful scourges to ever afflict humankind.  I shied away from writing about the physiological aspects of the disease–which is caused by two viruses, Variola major and Variola minor–because the symptoms are absolutely horrible (as I can fervently attest after some internet research involving photographs which were apparently taken in the cruelest depths of hell).  Smallpox was badly named.  It should have been called “deathrash” or “bloodskin” or “face-melt-fever”, but apparently Roman stoicism came to the fore and the Latin name merely means “spotted” or “pimple.”  Not only did smallpox effectively kill off the native population of the new world (and later of Australia, which experienced a similar plague), but for thousands of years it regularly culled a sizable hunk of humanity from Africa, Asia, and Europe.  Like influenza, the smallpox co-evolved in response to our immune reactions to it, so, even in parts of the world where people had inherited some resistance, the pestilence sometimes flared into a full scale pandemic.

Death and the Child (Sebald Beham, woodcut, early 16th century)

But smallpox is gone (almost)!  Humankind joined together and beat one of the most horrible things we have ever faced.  Today the last remaining live smallpox viruses are imprisoned in laboratories in Atlanta and Koltsovo, Novosibirsk Oblast.

In grade school, we were taught that this stunning victory came about when an English physician named Edward Jenner realized that milkmaids who contracted a mild rash called cowpox became immune to smallpox.  By deliberately giving people cowpox, Jenner found a way of protecting them from the fatal smallpox.  Jenner thus invented immunology, one of the most useful and inexpensive forms of medicine.  His great work was taken up by subsequent generations of immunologists and physicians in allied fields who improved upon his findings.  Together they used national and international resources to immunize the world.  Smallpox was officially proclaimed to be eradicated in 1979.

Yet Jenner had antecedents who were not well appreciated because of the preconceptions and prejudices of the day, (also, by necessity, he worked with human subjects whose bravery went unheralded).  Jenner’s greatness is not diminished by looking back at the others who were involved in an epic struggle against history’s greatest killer.  There are descriptions of smallpox avoidance techniques in ancient Sanskrit texts from India dating back to 1000 BC, however scholars do not agree on whether these texts describe inoculation or not.  What is certain is that a medical text from Ming dynasty China does indeed describe an effective inoculation process.  The Douzhen xinfa  published in 1549 was written by Wan Quan, a pediatrician who believed that sunlight and fresh air were good for children (and that overfeeding and overmedicating were bad). Wan Quan described a method of variolation—by which means a healthy person was purposely infected with Variola minor, the less dangerous o the two forms o smallpox.  By the time of the Lonquing Emperor who reigned from 1567–1572 (and was the son of the addled Jiajing emperor) variolation was widespread–powdered smallpox scabs were blown up the noses of healthy children so that they would contract Variola minor.  This was effective in preventing smallpox, but it had a fatality rate of .05% to 2%–a dreadful margin (though nothing like the 30%+ mortality rate of smallpox pandemic).

Variolation gradually spread through the Chinese empire and through the Turkish and Islamic world, but it did not reach the attention of western medicine until the early 18^th century.  Lady Mary Wortley Montagu was the wife of the British ambassador to the Ottoman Empire from 1716 to 1717 (as well as a sort of feminist pioneer, poet, and adventurer). After losing a brother to smallpox (and being disfigured by the disease) Lady Mary was eager for a means to protect her children from the scourge.  In 1718, the embassy surgeon inoculated her son and, based on the success of this procedure, she arranged for her daughter to be inoculated in 1721 (when the family was back in England).  The procedure attracted the attention of the medical establishment and the royal family.  Although many doctors were aghast at an “Oriental” procedure (which was being popularized by a woman, no less) the royal family intervened directly in the controversy when a smallpox epidemic swept England in the 1720s.  In order to fully test the safety of the inoculation, the King offered a full pardon to six (or seven?) condemned prisoners in exchange for undergoing variolation.  Not surprisingly the condemned prisoners chose an unknown medical procedure instead of the hangman’s rope, and when they survived they were duly freed.  Variolation was also tested on six orphan children–who also survived.  After these human tests, the royal children were inoculated against smallpox.

Lady Mary Wortley Montagu with her son, Edward Wortley Montagu, and attendants (Jean Baptiste Vanmour, ca. 1717, oil on canvas)

Inoculation spread quickly among the rich and powerful of Europe, but it was staunchly opposed by reactionaries and by churchmen (who believed it was contrary to God’s will).  Against such a background, came Jenner’s discovery of a cowpox based vaccine which was vastly safer than using live smallpox.  But even with the much safer vaccine, it was a long time before the immunologists started to win over many ignorant and superstitious people to the life-saving virtues of the vaccine (and nearly two hundred more years before they stomped out the loathsome blight of smallpox).

The Smallpox Plague

The second Monday of October is celebrated in America as Columbus Day. The holiday commemorates the day when Columbus’ exploratory fleet first spotted land on October 12, 1492.  Before Columbus, many other people had discovered America in one way or another, but after Columbus arrived, everything changed.  People, animals, diseases, ideas, and art all began to rapidly flow back and forth between the hemispheres in a way which had never before happened.  Today’s post, however, is not about the (always-controversial) Columbus–instead it is about the most terrible new export which the Spanish brought to the new world.

The exploration and colonization of the Americas were made easy for Europeans because big parts of the continents were empty.  Early explorers reported fields that were ready for farming, and orchards filled with fruit but no people.  The reason for this emptiness is sad and deeply troubling.  Smallpox came to the Americas in the early 16^th century on Spanish ships and rapidly expanded into a vast pandemic which ravaged the population of the new world.  It outpaced the European explorers in conquering the continents: by the time colonists and explorers reached the hinterlands, great swaths of North and South America were uninhabited: the people who had lived there were dead from the highly contagious virus.  Native Americans had not co-evolved with the disease for millenia (like Europeans, Africans, and Asians had) and the people of the first nations died in droves.  Some estimates put Smallpox mortality in indigenous populations at an astonishing 80% to 95%.   Historians estimate that the original population of the Americas was between 50 and 100 million (approximately the same as Europe).  The conquest of America was not by guns or ships or religions, it was by disease.  The great smallpox plague is one of the more important events in history–yet it is has not been a focus of mainstream popular history both because Europeans did not directly witness the worst ravages (except in rare cases) and because there is an existentially terrifying randomness to the mass death of so many people.

In the old world, smallpox was an ancient scourge dating back to prehistory.   Using genetics, scientists have estimated that the virus originated 10,500 years ago and, indeed, 3,000 year old Egyptian mummies have been found bearing evidence of the disease.  During the 17^th century, smallpox killed an estimated 400,000 Europeans per year (and left many survivors blind or hideously scarred). The people of the Americas escaped this scourge entirely by crossing a landbridge from Asia before smallpox evolved.   When the Vikings discovered America, they found a resilient culture which easily shrugged off attempts at colonization.  Crucially none of the Norse explorers or colonists brought any terrible illnesses with them.  But what had been fortunate for the first Americans became a terrible weakness, when smallpox did finally arrive with the Spanish.
The scope of the great dying boggles the imagination.  A Spanish priest traveling with Cortes into the dying Aztec empire described the scene writing “As the Indians did not know the remedy of the disease…they died in heaps, like bedbugs. In many places it happened that everyone in a house died and, as it was impossible to bury the great number of dead, they pulled down the houses over them so that their homes become their tombs.”

Of course the Spanish did not know the remedy for the disease either.  It is a historical fluke that the people of the new world died by the millions in the decades after Columbus rather than the other way around (and wouldn’t that have been a twist?).  In fact syphilis was a new world disease unknown in Europe until adventurers brought it across the Atlantic.  The story of the smallpox plague is a dark and terrible one, but it does have a more positive corollary.  In the 16th century, as the conquistadors unwittingly spread pestilence into North and South America, a solution to the terrible plague had already been perfected on the other side of the world in China.  Thanks to Chinese physicians, Turkish diplomacy, an English nobleman, convicts and… milkmaids (and lots of careful work), the horrible scourge has been all but eradicated from Earth, but I will save that brighter story for tomorrow.

Smallpox among the Aztecs