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Authors: Laurie Garrett

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If a human host was most unlucky, the parasites coursing through her bloodstream would be
P. falciparum
and she would have only twelve days to realize she'd been infected and get treatment of some kind before the disease would strike, in the form of either acute blood anemia or searing infection of the brain. In either case, for an individual whose immune system had never before seen
P. falciparum
, the outcome would likely be death.
Scientists knew that injected sporozoites made their way to the liver, where they underwent another transformation, becoming so-called schizonts capable of infecting red blood cells. By the millions the tiny creatures, matured into merozoites, multiplied and grew inside red blood cells, eventually becoming so numerous that the cells exploded. Soon the human body would be severely anemic, its every tissue crying out for oxygen. If the immune system managed to keep the merozoite population down to manageable levels, the results would be prolonged—perhaps chronic lifetime —fatigue and weakness. Unchecked, however, the merozoites would so
overwhelm the red blood cell population that the host's brain, heart, and vital organs would fail and death would result.
During the merozoite invasion of the blood supply, a smaller number of male and female gametocyte-stage P. falciparum would also be made, and the entire cycle of events would repeat itself when another female Anopheles mosquito fed on the blood of the ailing human, sucking those gametocytes up into her proboscis.
Understanding that process of the disease was relatively easy; more difficult was predicting when and why humans and Anopheles mosquitoes were likely to come into fatal contact and how the spread of malaria could be stopped.
Several types of monkeys were known to serve as parasite reservoirs, meaning that for long periods of time the disease could lurk in monkey habitats. The
Anopheles
mosquito would happily feed on both the monkeys and the humans that entered such ecospheres, spreading
P. falciparum
between the species.
17
The size of
Anopheles
mosquito populations could vary drastically in a given area, depending on rainfall, agricultural practices, the nature of human housing and communities, altitude, proximity to forests or jungles, economic development, the nutritional status of the local people, and numerous other factors that could affect mosquito breeding sites and the susceptibility of local human populations.
18
Almost entirely absent in the mid-twentieth century was an intellectual perspective that wedded the ecological outlook of the classical parasitologist with the burgeoning new science of molecular biology then dominating the study of nontropical bacteria and viruses. Money was shifting away from research on diseases like malaria and schistosomiasis. Young scientists were encouraged to think at the molecular level, concentrating on DNA and the many ways it affected cells.
Imbued with profound optimism, coupled with the post-World War II American “can do” attitude, the world's public health community mounted two ambitious campaigns to eradicate microbes from the planet. One effort would succeed, becoming the greatest triumph of modern public health. The other would fail so miserably that the targeted microbes would increase both in numbers and in virulence, and the
Homo sapiens
death toll would soar.
Humanity's great success story would be smallpox.
In 1958 the Soviet Union went before the World Health Assembly—the legislative body of the World Health Organization in Geneva—to request an international campaign for the elimination of smallpox, winning virtually universal support.
Historically, smallpox had proven a particularly vicious killer. It did not, as was typical for most infectious diseases, preferentially attack the most impoverished members of society.
19
In A.D. 165, the Roman Empire was devastated by an epidemic now believed to have been smallpox. The pestilence raged for fifteen years, claiming victims in all social strata in such high numbers that some parts of the Roman Empire lost 25 to 35 percent of their people.
20
It is believed that the virus struck a completely nonimmune population, having first appeared in Asia some one hundred years earlier.
21
Over subsequent centuries equally devastating pandemics of the viral disease claimed millions of lives in China, Japan, the Roman Empire, Europe, and the Americas.
22
According to historian William McNeill, Cortez's capture of Mexico City with just a small army of exhausted Spanish irregulars under his command was possible only because the Europeans had unknowingly spread smallpox throughout the land. When Cortez launched his final assault on the capital, few Aztec soldiers were alive and well. Smallpox, together with measles, tuberculosis, and influenza, claimed an estimated 56 million Amerindian lives during the initial years of the Spanish conquest.
23
By 1958, when the Soviets called for global eradication, smallpox was killing 2 million people a year, and cases could be found in thirty-three countries.
The virus could be spread by touch or respiration, and scientists carefully calculated the infectious dose necessary to produce disease—the numbers of viruses present in a tiny droplet of human exhalant and other details of transmission. It turned out that a single milliliter droplet of human lung exhalant contained 1,000 more viruses than were necessary to produce infection in the unfortunate soul who inhaled that minuscule bit of moisture.
24
Both the historic devastation and the widespread rates of contemporary infection seemed to argue for skepticism about smallpox eradication.
On the other hand, several aspects of the biology of smallpox gave cause for optimism. Foremost was the existence of an extremely effective vaccine that, in various forms, had been in use since 1796.
25
In modern times the cowpox vaccine, made from the bovine form of the virus, had been perfected, making it over 99 percent effective, with virtually no side effects. Smallpox was also easy to diagnose, and cases of the disease could readily be spotted by people with no professional training. During severe illness, grotesque bulbous inflammations formed on the individual's face and skin. The distinct poxing, once healed, left visible scars anybody could recognize.
Because the virus was spread directly from person to person there were no troublesome vectors to control, such as mosquitoes, rats, ticks, or fleas. And the very thing that made smallpox so terrifying—its rapid lethality—also rendered it controllable because the viruses multiplied and spread so quickly that most people were infectious for only four or five days and their
debilitation was so great that they could not walk about and infect large numbers of people.
Though eradication would require over 250 million vaccine doses per year and a worldwide effort to reach all citizens at risk for smallpox—even those in the midst of wars, social tyranny, famine, or disaster—the program began amid optimism in 1967 under the leadership of American physician Donald “D. A.” Henderson.
26
Nations of the Northern Hemisphere and Latin America were already well on their way to smallpox eradication in 1967, but the disease was firmly in place in many parts of Africa and Asia, where religion often proved a major barrier to vaccination.
Before the campaign began, researchers scoured pilot project areas to see how accurately smallpox cases were reported. Their conclusion was that an astonishing 95 percent of all cases of the disease were never reported to national or international public health authorities. The reasons for such dramatic underreporting were numerous: local authorities feared being penalized if higher-ups learned that epidemics had occurred in their jurisdictions; in some areas the disease was simply accepted as a fact of life; outbreaks tended to occur in confined areas and could easily be missed by quick national surveys; during centuries of colonialism, people's homes were often burned if smallpox was found in a family member, so people in former colonies naturally concluded it was best not to inform authorities.
27
Ultimately, Henderson's team at WHO devised a smallpox plan of attack that boldly confronted these issues by dispersing dozens of skilled tropical disease experts all over the world in search of small outbreaks of the virus. Once such an outbreak was identified, local government was mobilized and residents of the area were vaccinated. Inoculation was occasionally carried out forcibly; in some instances people's homes were invaded and local police assisted the inoculators.
Because both superpowers wholeheartedly supported the campaign, few governments resisted public health efforts that often took on military overtones. The WHO teams braved civil wars, floods, religious battles, and a variety of geographic and logistic problems to accomplish their task in eleven years.
In Bangladesh, for example, where the worldwide campaign faced its toughest battle due to the great population density and ancient smallpox endemicity, French physician Daniel Tarantola braved confrontation with an infamous murderer thought to be a smallpox carrier. Without police protection, Tarantola approached the murderer and his outlaw gang in their hideout and faced down guns to immunize them. The word from villagers was that members of the gang had classic pockmarks on their faces and the robbers were spreading the epidemic throughout the countryside. The village intelligence proved accurate, and the immunizations prevented a local epidemic. The gang leader, however, died of smallpox two days after Tarantola's courageous confrontation.
During the late 1960s, Tarantola, then a Paris medical student, volunteered his services to Médecins Sans Frontieres, an idealistic organization that sent European medical volunteers into war-torn areas to provide care to civilian populations. In the midst of civil war, the twenty-something Tarantola ran a pediatric ward in Biafra. Two years later, with some course work yet to be completed at the University of Paris Medical School, Tarantola signed on for a two-year stint in Africa in a small hospital in newly decolonized Burkina Faso.
Tarantola was a product of his times. While he studied the intricate workings of human kidneys, riots raged in the streets of Paris. Students formed alliances with factory workers and, inspired by such heroes of the day as Mao Zedong, Che Guevara, Ho Chi Minh, Herbert Marcuse, and Kwame Nkrumah, challenged the very existence of the De Gaulle government. Such bold, youthful actions were reflected all over the world, from Washington to Jakarta, as college-age young adults challenged the established order of things. A mood of activism and boldness infected the usually staid halls of medical schools internationally, inspiring would-be physicians like Tarantola to dream of a world in which villagers in Burkina Faso had as much a right to expect an eighty-year life span as did les parisiennes bourgeois.
When young doctors like Tarantola looked around the world for inspiration in the 1960s, they saw people nearly their own age leading revolutions against the old European colonial powers, taking control of governments and debating the creation of new types of social orders. Like many European and American idealists, Tarantola thought that with enough energy and Western money, just about anything was possible “if there is political will.”
It was with that zeal that he approached his work in the Fada N'Gourma Rural Hospital in Burkina Faso, developing a grass-roots primary health care system that radically reduced infectious disease problems in the area. For his efforts, Tarantola was given the 1973 Albert Schweitzer Award.
The ink was barely dry on his medical degree when Tarantola next signed on with another French charitable group, Brothers to All Men, to do primary health care in northern Bangladesh. Because he had no command of English, the second language of Bangladesh, Tarantola promptly taught himself Bengali.
He had been in the country only six months when he was recruited to work with the smallpox campaign. Like Tarantola, most of the smallpox investigators were young (under thirty-five), Caucasian, idealistic males from Europe and North America. At the time, this cultural and gender homogeneity made some team members uncomfortable, but the grander goal of eliminating one of the planet's most notorious scourges outweighed concerns about neocolonialistic appearances.
In 1972 Don Francis had just barely completed his pediatrics residency at Los Angeles County Hospital and signed on with the CDC when smallpox broke out in Kosovo, Yugoslavia. The young doctor was just setting up a
CDC disease surveillance office in Oregon when Atlanta called, ordering him to go to Belgrade. Francis raced home, grabbed a few changes of clothing, a shaving kit, and his passport, and headed for the airport. Seven hours later he was in Washington, D.C., getting a briefing and cases of vaccination equipment. Before midnight he was asleep on a jet flying somewhere over the Atlantic, and in the morning he hit the ground running in Belgrade.
A few weeks later, the Yugoslavian outbreak safely contained, Francis was in Khartoum, the capital of Sudan, hunting down smallpox cases. From there, he went on to India and Bangladesh.
By the time Francis's obligations to the smallpox campaign were fulfilled, nearly three years had elapsed since he answered that phone call one morning in Oregon.
Another young American physician, David Heymann, saw a one-shot CDC assignment turn into two years of Indian smallpox hunting in Bihar and Calcutta. When Heymann's group vaccinated somebody, they always showed pictures of smallpox-stricken Indians and asked for names of people suffering from the disease. In some areas they offered rewards to people who could steer the team to active smallpox cases. If they found a case, the ailing person was quarantined and everybody in the region vaccinated—some against their will.
Despite the coercive nature of their activities, few of the fieldworkers doubted that, in the greater scheme of things, what they were doing was just: if 2 million people a year could survive because of momentary inconveniences visited upon a few, then how could there be any doubt about the righteousness of their campaign?
The one concern that did constantly haunt D. A. Henderson and his team was the cost of failure. In those brief moments when they allowed themselves to entertain the notion that smallpox might not be eradicated, the scientists knew the world might never again be willing to mobilize across political, national, cultural, racial, and religious boundaries to share a common battle against disease. The stakes, clearly, were high.
By the summer of 1974, the WHO team was about to declare victory in Bangladesh, the last stubborn holdout of the virulent variola major form of smallpox. Officials had even gone so far as to publicly predict that complete elimination of the virus would occur before that November.
But then the rains came, and came, and came. By August, Bangladesh was besieged by water, as dikes and dams burst under the monsoon's force. Refugees poured by the tens of thousands into Dhaka. Famine spread throughout the land, and the country seemed to be coming apart at the seams. Shortly before the floods, the Prime Minister, Sheik Mujibur Rahman, was assassinated, and a series of riots, civil violence, and coups followed, lasting well into 1975.
After being so close to victory, the task of eliminating—indeed, amid
the chaos,
finding
—the remaining cases seemed so daunting that most of the eradication staff gave up. They were exhausted, burnt out.
But Tarantola told his staff, “Look, this just means we have to get down to micromanagement. We must look at the trees now, not the forest. Take it day by day.”
Slowly staff confidence and morale were rebuilt, smallpox cases were found, and the enthusiasm returned. Within a year, victory once again seemed within grasp. Heymann and Francis were reporting total success in India, and no new outbreaks had occurred in Africa in months. With all eyes on Bangladesh, excitement rose.
One of the last infected villages was outside the city of Chittagong, which was under the command of an Army general. Not knowing what side of the civil war that general was on, or how he felt about foreigners, Tarantola confronted the general and requested permission to vaccinate the villagers. Permission was initially denied, and the disease spread. Once again, it seemed the gigantic obstacles of Bangladesh would force the WHO team to snatch defeat from the jaws of victory.

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