The Anthrax Letters: The Attacks That Shocked America (22 page)

The idea to rid the world of smallpox was not entirely new. Resolutions to eliminate smallpox as well as malaria and yellow fever had been endorsed by the WHO. But actual efforts, such as they were, had failed. The extraordinary ambition of such an undertaking competed with the cold reality that no disease had ever been rendered extinct through human effort. Yet certain characteristics of smallpox, which is caused by the
variola
virus, seemed to make it amenable.

In the first place, the only natural host in which the
variola
virus can survive is a human being. Some killer microorganisms, like anthrax bacteria, can thrive in animals or lay dormant in the soil for years. But in the case of smallpox, if human infection is eliminated, the virus disappears from any natural setting.

In addition, a single vaccination against smallpox provides immunity for years. So vaccinating enough people should mean that the virus at some point would have no natural habitat in which to “live.”

Still, not everyone was happy about the proposal for a global initiative. “D.A., I’m furious,” complained Alexander Langmuir, who as chief of epidemiology at the CDC was Henderson’s boss. Langmuir believed the plan was so ambitious that it would drain resources from his own CDC programs. “It will destroy the Epidemiological Intelligence Service,” he railed.

Other prominent figures were convinced that an eradication program could not succeed in any case. One was Marcolino Candau, the director-general of the WHO. He believed that success would require vaccinating every last person in the world, an impossible task. But since the campaign would be global, the proposal was put in the lap of the World Health Assembly, the deliberative body of the WHO, which meets annually. In May 1966, after several days of debate, the 120-odd member states voted to support an eradication campaign by a margin of two votes.

Candau faulted the United States for what he was sure would be a failed program. “He wanted an American running the program, so that when it went down the tubes the U.S. could be blamed,” said Henderson. Since Henderson had been leading the CDC’s measlessmallpox program in Africa, Candau asked that he be appointed director of the new global initiative. Henderson protested:

Did Henderson think it medically possible to eradicate smallpox?

When the program began in 1967, smallpox was endemic in more than 30 countries. The WHO eradication campaign was to take 10 years. By mid-1968, after the first 18 months had passed, Henderson felt he had made progress. He decided to remain at the helm a bit longer. In the end, he did not step down until 1977, the year that the last case of endemic smallpox was found.

At the outset, Henderson had no masterplan. But as the program went from region to region, cumulative efforts led to successes. “Our last case in West Africa was in Nigeria in 1970, then Brazil in 1971, Indonesia in 1972.” By then the program was being phased in elsewhere—in Afghanistan, Bangladesh, India. Beyond earlier efforts to simply immunize as many people in a region as possible, the strategy came to be based on disease surveillance. Local health authorities would deliberately seek to learn about any outbreak of smallpox. When a case was detected, they would isolate the infected patient and vaccinate everyone the patient had been in contact with. This manner of containment became known as the “ring” approach, by which a circle of immunized people would become a barrier to new infections beyond their perimeter.

The strategy ultimately proved successful. But the effort could be harrowing. In
Smallpox and Its Eradication
, a book produced by the WHO (1988), Henderson listed the formidable obstacles faced by workers in the field: famine, flood, epidemic cholera and other diseases, and frequent changes of governments whose interest in cooperating varied. The most dangerous challenge came from civil wars and local conflicts.

Dr. Donald Millar, who led the CDC contribution to the global program, was engaged in field operations in several countries. “I was placed under house arrest during coups seven times,” he recalled in a genteel Virginia drawl. “Togo, Ghana, Benin. In Nigeria the civil war was fought while we were there.” Although he was never injured, he often worried.

As Henderson observed, the only power possessed by WHO was that of “moral suasion.” From the beginning, Henderson realized that the country that posed the greatest challenge to the eradication effort would be India. “Of the 1.1 billion people living in areas which had endemic smallpox in 1967, 513 million lived in India,” he noted. In fact, the
variola
virus is thought to have evolved into a human killer on the Indian subcontinent. In the mid-20th century, half of the world’s 2 million annual smallpox fatalities were in India. The country’s large land area, its poor system of health reporting, and its huge mobile population—-millions on religious pilgrimages and other travels—had undermined previous efforts to control the disease there.

But with the participation of local and regional health authorities, in 1973 the WHO intensified its outreach efforts. Workers fanned out to villages and markets to find recent cases. Photographs of a smallpox patient and promises of reward for finding other patients were posted in markets and teashops. Workers stationed at market entries would ask people if they knew of any cases and which village they were from. In one district, in Assam, 34 of 695 villages were found to have had cases of smallpox. When a case was identified, quick action followed, as described in
Smallpox and Its Eradication
:

At the same time, “vaccinators” would try to reach every person within a 1-mile radius of an outbreak. Just how difficult the effort could be was exemplified in Puri village, a pilgrimage site of the Jain religion. In December 1974, at the height of the pilgrimage season, 40 Puri households had become infected. Henderson noted that many Jains resisted vaccinations even after their religious leader “reluctantly agreed” to recommend them. In consequence, the entire village was quarantined by military police, and Jains were kept from the area unless they were vaccinated. By that time a pattern had become established. As described in the book:

By the beginning of 1975, smallpox remained in only 285 of India’s 575,000 villages. But challenges to the eradication efforts had not eased. Here are excerpts from a report at that time by a region supervisor in Bihar, an Indian state on the northern border near Nepal:

The most stunning sentence of the report was: “Vaccination was possible only when we climbed over the compound walls and forcibly inoculated each family member.” Such extraordinary efforts led to continued progress. The last case of smallpox in India was identified in May 1975. She was Saiban Bibi, 30, a homeless beggar who had lived on a railway platform in Assam. Bibi was brought to a local hospital where four guards were assigned to make sure that she remained isolated. During the next 2 weeks, searches and surveillance were intensified at locations that were serviced by the railroad. No additional cases were found.

India celebrates Independence Day on August 15. In 1975 that day included special recognition of India’s freedom from smallpox. “It was a great event,” Henderson recalled, relishing the memory. “There were parades, the WHO staff was there, the Indian health workers. We were given plaques and medals, and we were draped with garlands.”

More than 100,000 workers, including interviewers, vaccinators, and watchguards, had participated in the country’s eradication program. The monumental success was captured by a simple chart that appeared 2 years later. In 1974 the number of smallpox cases in India was listed as 188,003; in 1975 the figure was 1,436; in 1976 it was zero.

The eradication campaign continued in other countries, but after India, Henderson said, “we felt we were going to make it.” Two years later that expectation was fulfilled. On October 26, 1977, in Somalia, a thin 23-year-old cook was diagnosed with smallpox, the last naturally occurring case on earth. “And so the final chapter was written,” Henderson later recorded. “Ali Maow Maalin represented the last case of smallpox in a continuing chain of transmission extending back at least 3000 years.”

A sad postscript occurred in 1978 when Janet Parker, a medical photographer at the University of Birmingham Medical School, died of smallpox. She had become infected with virus that had escaped from a laboratory one floor below the one on which she worked. No cases appeared after that, and on May 8, 1980, the World Health Assembly declared that the battle against smallpox was over and vaccinations would no longer be necessary.

Shortly before the 1991 Persian Gulf War, Henderson ended his tenure as dean of the Johns Hopkins School of Public Health. He had accepted an appointment as associate director of the Office of Science and Technology Policy, an advisory body to the president of the United States. The possibility that Iraq might use biological weapons was being discussed, “but we weren’t overly concerned,” he said. The United States did not yet understand the extent of Iraq’s germ warfare program. Henderson continued in government service under the Clinton administration, becoming deputy assistant secretary for health at HHS. But he left that post in 1995, a year he describes as a watershed.

In 1995, Saddam Hussein’s son-in-law, Hussein Kamel Hassan, defected to Jordan. Kamel had overseen Iraq’s development of weapons of mass destruction. His defection prompted the Iraqis to admit to a much larger biological weapons program than they had been acknowledging to United Nations weapons inspectors. Around the same time, the public was hearing more from Ken Alibek and other Soviet defectors about the expansive biological program they had run in the former Soviet Union. It was also the year that Aum Shinrikyo, a Japanese cult, released sarin nerve agent in the Tokyo subway. Although sarin is a chemical, the incident suggested one way in which a biological agent might easily be unleashed. “This was when I began to become concerned. But even then, to tell you the truth, I didn’t really do much about it,” Henderson acknowledged.

His worries ripened in 1997 after passage of the Nunn-Lugar-Domenici Domestic Preparedness Act (named for Senators Sam Nunn, Richard Lugar, and Peter Domenici). The legislation provided $36 million to the Department of Defense and $6.6 million to the Public Health Service to train police, fire, and other responders in 120 cities to deal with mass casualty attacks. Henderson, however, was not pleased: “It became apparent to me that the responses were being crafted by police and chemical and military people. It was all focused on ‘bang’ or on gas release. There was very little attention being paid to biological.”