Two Faces of Smallpox

The English patients' faces were spotty, and the English health officers' faces were red. For in the industrial Midlands, less than a hundred miles from the birthplace of vaccination, no fewer than 24 Britons had come down with smallpox by last week. Both patients and health officers were lucky. They had no idea what traveler had carried the disease or where he had come from, but the smallpox proved to be the mild form, variola minor or alastrim. Only ten patients had to be hospitalized; the rest could be treated at home--with, so far, no deaths.

News of the outbreak had a particular significance for international health workers, 400 of whom were meeting in Geneva to discuss the World Health Organization's plans for a massive, ten-year effort to stamp out smallpox all around the globe. Western Europe and North America, WHO estimates, now spend $70 million a year on vaccinations to protect themselves against a disease that occurs nowhere within their borders. Why not allocate a fraction of this, $180 million over ten years, to exterminate the smallpox virus wherever it still flourishes? Then, the argument runs, many fewer vaccinations and revaccinations would be needed.

Jet-Borne Virus. The problem may be more difficult than the finances suggest. The world's greatest smallpox reservoir is the Indian subcontinent. In the 1950-51 winter epidemic season, the Republic of India recorded 225,000 cases and 57,000 deaths. By herculean efforts involving 420 million vaccinations, India has cut the toll, and the 1965-66 figures are expected to be closer to 10,000 cases and 2,500 deaths--an enormous achievement, even allowing for continued underreporting. The improvement has been made despite manpower shortages, and the fact that ordinary vaccine will not keep for more than a day in torrid India.

Pakistan reports a comparable success in reducing smallpox, especially in its detached eastern portion, even though vaccinations have reached only about 30% of the population. Yet it was from Pakistan that five jet-borne immigrants started Britain's 1962 epidemic of the more virulent and deadly form of the disease, variola major, that claimed 62 victims and caused 24 deaths. Suddenly, Britain, which had abolished compulsory vaccination in 1948, had to scrap its small annual vaccination budget of $650,000 and stage a $3,800,000 crash campaign. Since then, there have been half a dozen outbreaks in Europe. Today, although Britain has tightened its rules, there is still no universal vaccination. Traveling Britons find themselves in the embarrassing position of being required to get vaccinated before they can enter Spain or Cyprus or even their own colony of Gibraltar.

Dry the Wellsprings. The U.S. has a different problem from Britain's, but it is no less difficult. There have been no smallpox deaths in the U.S. since 1949, and public health authorities attribute the immunity to universal vaccination. A more likely explanation is that 95% of U.S. civilians couldn't catch smallpox if they tried. The virus travels only from man to man--through the air, by physical contact, from the dust of drying pox scabs, and thus from clothing and bedding--and the average American never gets within 1,000 miles of a case. What counts most is that no one is allowed to enter the U.S., whether returning resident, immigrant or transient, without proof of recent vaccination.

For travelers, this makes good sense, says the University of Colorado's Dr. C. Henry Kempe. Not for the stay-at-home. Vaccination itself is not always harmless. It may cause a fatal reaction in young children with eczema, and at later ages a severe or deadly encephalitis. In 1962, Britain had 15 vaccination deaths. Since the last American smallpox death, Kempe estimates, there has been an average of 15 deaths each year from vaccinations. Taking the traditional smallpox death rate of 30%, this means, he argues, that there would have had to be 600 or more cases of smallpox in little more than 15 years.

Smallpox, like polio, can indeed be eradicated. But while such countries as India (with massive support from Russia, which has supplied more than 400 million doses of heat-resistant, freeze-dried vaccine), and others in Asia and Africa, try to dry up the wellsprings of the epidemics, highly sanitized Western countries can abandon dangerous routine vaccinations only if they enforce rigid safeguards on travelers.

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