Veterans of the War that Saved the World

Tonight was the dinner jointly organized by the UPMC Center for Health Security and Johns Hopkins University's Bloomberg School of Public Health in honor of DA Henderson, the founder of our center and a former dean of the school. 

It was an extraordinary event and one that I will remember for a lifetime. Sitting in a room of luminaries of public health including Army generals, two former CDC directors, an undersecretary of the Department of Homeland Security, and countless others would be an extraordinary conglomeration for anyone but DA. 

Scattered amongst the attendees were those that worked on the smallpox eradication campaign, DA's pathbreaking achievement that rid the planet of a murderous virus. Listening to these heroes trade stories from the 1960s and 1970s about how they, under DA's guidance and direction, vanquished this virus from remote corners of the planet -- a feat one of them called more important than the moon landing -- was inspirational. I imagine listening to true war stories of military veterans is a similar experience but I would argue the veterans I heard converse tonight are of a different sort: these were the veterans of the only successful war to save mankind from a virus that had killed with impunity until it met DA and with him as their commander-in-chief they saved the world.

Infectious Disease & Colonial Politics: A Review of The Fever of 1721

I often wonder how people living before the germ theory of disease was discovered, before the causes of illnesses were known, and before any effective treatments were available coped with infectious disease outbreaks. How did they go about their lives, continue their businesses, and plan for the future. 

A new book, gaining some attention, shows how one community coped with such an outbreak. In The Fever of 1721: The Epidemic that Revolutionized Medicine and American Politics Stephen Coss provides just such a glimpse. The etiology of this particular fever, that occurred in colonial Boston, was smallpox, the scourge of humanity that was thankfully vanquished by the bifurcated needle wielded by DA Henderson. 

What makes the smallpox outbreak notable was that it was one of the first in which people were not helpless and could, borrowing the title from another important book on smallpox, defy Providence via inoculation. As I've written before, inoculation -- as opposed to vaccination -- was a procedure long-practiced in Africa and Asia,  that involved taking the material of smallpox and scratching it into someone's skin. The mild case of smallpox that followed was protective against the sometimes fatal naturally-acquired smallpox.

In 1721, as the story goes, a fire-and-brimstone preacher named Cotton Mather -- someone who was involved (on the wrong side) in the Salem Witch Trials -- came across reports of inoculation in a scientific journal after he had also learned of it through one particular slave. This prompted a largely unsuccessful crusade to have Boston physicians adopt the practice--Dr. Zabdiel Boylston being the heroic exception. It is a mystery to me how someone could be so compartmentalized intectually that they could participate in the Salem Witch Trials also support the cutting-edge science and exemplar of rationality that was inoculation.

What was peculiar about this situation--and this is one of the underlying themes of the book--is that Mather was very caught up in the politics of the colony and drew the ire of a particular newspaper, the New-England Courant, run by James Franklin assisted by his apprentice and younger brother Benjamin Franklin. The newspaper ran diatribes against inoculation and parodies of it (labeling it was a way to spread smallpox amongst Indians) but also general political commentary that was biting, incisive, and challenging to authority. It was even associated with Satanism! 

The tension was so high in the city that Mather's house was firebombed -- something I hope the anti-vaccine movement doesn't emulate. James Franklin wasn't anti-inoculation per se, but surely published anti-inoculation material. However, after seeing the benefits of inoculation during the Boston outbreak Benjamin Franklin became the "country's foremost inoculation evangelist." 

Inoculation, based on the results in Boston and in England, became an important component of smallpox control and was embraced by many, including John Adams (a relative of Boylston) and George Washington. In fact, pre-emptive inoculation of the Revolutionary Army is considered one of Washington's most important strategic actions.

The distinct value of this book is how it expertly weaves the narrative of the outbreak and the controversies surrounding inoculation with the burgeoning of a distinctly American political conscience--the newspaper published Cato's Letters.

For those who want to understand how politics interacting with infectious disease in colonial America, there is, to my mind, no better book.

Understanding Vaccination Through the Lens of Inoculation: A Review of Defying Providence

When the history of vaccination is discussed it, naturally, begins with the path-breaking step taken by Edward Jenner in the late 1700s. Jenner’s use of cowpox to protect against smallpox—an action that would culminate in the eradication of smallpox from the planet under the aegis of DA Henderson—is often discussed without any knowledge of the context that conditioned the development of the first vaccine in history.

Dr. Arthur Boylston’s Defying Providence: Smallpox and the Forgotten 18th Century Medical Revolution provides that valuable context. Boylston’s book, which is the result of extensive research, adds much detail to the means of controlling smallpox that existed before vaccination – i.e. inoculation. Inoculation is often treated as a historical relic in the path towards vaccination and given short shrift by many and often damned as a means by which smallpox spread but it is much more than that, as Boylston shows.

Inoculation was an ancient practice that rose in prominence in England and Boston (under the direction of another Dr. Boylston) in the 1700s. It involved the intentional infection of someone with smallpox via a small cut in the skin. Such artificial cases allowed an often minor infection to ensue conferring immunity against natural infection. Make no mistake, the artificial infection was true smallpox and, in rare instances, could kill and also had the ability to spread. However, it is crucial to not drop the context in which it was used – a time in which smallpox was a major killer in which risk-benefit ratios strongly favored the use of inoculation.

Boylston’s book provides a much-needed history of how this practice gained in acceptance, how the evaluation of its efficacy led to the foundations of evidence-based medicine, and how a specific phenomenon led to Jenner’s innovation. 

The phenomenon of those who had cowpox being protected from smallpox is cloaked in the myth of the fair complexion of the milkmaid but the actual truth is much more interesting scientifically.

Cowpox was an affliction known to farmers and the inability of an inoculation to take (i.e. produce a case of mild smallpox) in those with cowpox began to be known before Jenner. Jenner and others reasoned that because of the resistance to inoculation, cowpox might be protective against smallpox infection. In effect, Jenner sought to substitute vaccination (with cowpox) for inoculation, seeing if artificial cowpox would work the way natural cowpox did with respect to smallpox protection. Vaccination was a relatively safer alternative to inoculation and could not spread smallpox. The resistance to Jenner’s vaccination that occurred upon introduction can be seen not just as a reaction against the use of material from a cow but also hesitancy to discard inoculation, which had been a major component of smallpox control until then.  Indeed inoculation, as the title of the book makes explicit, allowed humans to defy Providence and take charge of the trajectory of their lives by protecting themselves from smallpox.

Dr. Boylston deserves much credit for writing this important history and illuminating the origins of vaccination—another means to defy Providence—by giving much due credit to inoculation and the inoculators.

Smallpox and Stage Fright

I'm currently listening to the audio versions of the multi-part Lyndon Johnson biography by Robert Caro and, especially for those who like the Netflix series House of Cards, it is a must read as it portrays naked power-lust and secondhandedness on a grand scale. 

One infectious disease tidbit that I found in the books is interesting. Describing Lady Bird Johnson, the books relate that as a child she was so afraid of public speaking that she hoped that if she ended up salutatorian or valedictorian of her high school and was required to give a speech at graduation, she would contract smallpox and be excused. She ended up 3rd in her class. 

That's a bad case of stage fright for a future First Lady. 

With a mortality rate that could reach 30%, wishing for chickenpox or influenza would be much more advisable than hoping for smallpox.

Today, modern stage fright sufferers don't have the "luxury" of wishing smallpox on themselves as DA Henderson has removed that option.

Grave-robbers, No Need to Fear Smallpox

Since smallpox has been eradicated from the planet, thanks to DA Henderson, the human population has little to no immunity to this deadly pathogen. This fact is what prompts concern about its use as a bioweapon. 

In lectures, I often say that one case of smallpox represents a likely bioterror event. However, a recent paper published in Emerging Infectious Diseases details the ability of smallpox to persist in relics (corpses, scabs). 

The conclusion of this interesting paper is that historical relics do not pose a major threat of smallpox exposure as infectious viral particles have not been recovered from myriad samples, though viral DNA has been discovered. 

So grave-robbers are likely safe from this pathogen.