Scourge: The Once and Future Threat of Smallpox

Reviewed by: John S. Marr, MD, MPH

Disclosures

November 13, 2001

Introduction

The title of this recently published book captures its contents like a haiku: scourge, once, future, threat, and smallpox. The 2 book-ended words, scourge and smallpox, precisely enclose 3 simple words about the past, present, and possible future of a scabrous disease. The titles to the 12 chapters are also heuristic invitations presented to the reader, from "The Monster on Death Row" to "The Unfinished Conquest." This book, written for a primarily lay audience, should be an enjoyable literary adventure for both the general public as well as those involved in the medical sciences. It is a literate, informative, and well-written narrative of the past, and even future unwelcome Wellsian "things to come."

Wisely, author Jonathan B. Tucker -- an expert on chemical/biological weapons proliferation and arms control and Director of the Chemical and Biological Weapons Nonproliferation Program -- does not clutter the text with footnotes that others use to purport scrupulous research. However, some important historical citations, such as Moore's History of Small-Pox (1815)[1] and Winslow's A Destroying Angel (1974),[2] are omitted.

Tucker does devote the initial 3 chapters to smallpox's virologic origins -- ancient, historical, and yesteryear accounts of its devastating effect on humankind, with succinct, accurate accounts and citations. These early chapters are but a prelude to the last 50 years of smallpox history, beginning in 1951 with epidemiologist D.A. Henderson.

Tucker warms to the young Henderson's epidemiologic investigations, following his career beginning at the (then) Communicable Disease Center, through his stewardship of the worldwide smallpox eradication program at the World Health Organization (WHO), to his most recent daunting challenges. The sundry strategies and brilliant innovations (such as 12 strokes of a bifurcated needle), as well as the many frustrations and bureaupathic challenges Henderson and his colleagues encountered, are engagingly detailed in the style of the late medical essayist Berton Roueché -- who could make the description of a chopped liver sandwich into a moveable feast. Tucker then leads the reader in an exciting search for the last natural case of smallpox that was identified in 1977. These middle chapters are a paean to Dr. Henderson, the Centers for Disease Control and Prevention (CDC), and the WHO.

What follows, beginning with a chapter aptly entitled, "Realm of the Final Inch," shifts from past accomplishments to newer concerns: the post-1977 eradication period, when there were ongoing disease surveillance concerns for possible cryptogenic smallpox foci, and the realization that a disease, now extinct in nature, but not in a test tube, augured new threats: accidental releases of the virus (as recounted in a British hospital laboratory accident in 1978), and other concerns that threatened to release the genie-scourge from the bottle.

After the CDC's and WHO's coordinated efforts to reduce access to the virus in countless, worldwide research facilities to only a few countries (the United States and former Soviet Union), Tucker documents the emergence of concern for the purposeful use of the virus as an agent of biological warfare by the former Soviet Union and, most recently, rogue countries and/or terrorist organizations. Indeed, Dr. Tucker has recently appeared as one of the expert "talking heads" on television after October 3 (the first report of anthrax), and when discussing smallpox, past and present, (and other biological terrorist threats), his knowledge is truly credible.

At the end of the book, in addition to a standard index, the author and his editors have also provided source notes for each chapter, allowing the reader to share his resources. There is also a section devoted to author interviews with experts in the field of smallpox research, eradication efforts, and the new concerns of bioterrorism. These source notes are user-friendly snippings and "pearls" that explain otherwise obtuse phrases, important dates, contextual quotations, and terminologies. They free the narrative from what would have been bothersome, footnoted distractions. Indeed, the chapters are glisteningly smooth and seamless. They are so well written that even rereading the accounts of ancient epidemics, Amherst's indecent proposal, Jenner's cowpox discovery, and smallpox 's role in biological warfare plans allows for a refreshing overview of standard historical and contemporary information.

There are some historical references that may be construed to be primary resources -- but, actually, many of them are not (for example, McNeill, and others).[3] This inadvertently may reinforce possible incorrect, biased orthodoxies as to the role of smallpox in the destruction of the Aztec (Nuahatl) and Inca empires. Important contributions to our knowledge of smallpox by Sydenham, Trousseau, Guanieri, Councilman, and others are absent.

Tucker also does not cite Roueché's classic 1947 article, "A Man from Mexico," about the New York City smallpox scare,[4] although he alludes to the event in a few paragraphs. For those of us who were on hand at the time, no one recalls it as "near-hysteria."[5] In fact, the incident is an example of those halcyon days when public health was at full throttle forward (vide infra).

The use of author interviews allows Tucker to insert conversations with people into the latter chapters, giving them a first-person excitement like a novel unfolding. There is never a question that the quotations are accurate, and because of this, the experts' actual quotations and predictions are often quite chilling.

Tucker generously describes the contributions of the dozens of people he interviewed, giving them dimensionality through crisp physical descriptions, professional back grounding, and substantial quotations, endowing the book with the air of a documentary movie.

It is clear that his knowledge, experience -- Tucker was the editor of another book devoted to chemical and biological weapons, Toxic Terror[6] -- and major interest are with events prior to September 11. It is as if his editorial stewardship of Toxic Terror was a prelude to his desire to focus on 1 agent (smallpox), instead of many. Indeed, in Toxic Terror, chapters were devoted to names and agents that are now familiar to all of us -- sarin/Aum Shrinrikyo (1995) and anthrax/Larry Wayne Harris (1998). By an unhappy happenstance, Scourge was published at the same time as anthrax incidents were emerging in the United States. Had these events not occurred, Scourge would have still been an impressive and important contribution to the medical literature. It is one of the better books recently published on the challenges now faced by the United States and its medical and public health agencies,[7,8] and it is devoid of gratuitous hand-wringing and finger-pointing.

Thanks to his easy access to experts like Henderson and others, Tucker argues well that "fortress America"[9] was and is vulnerable to external threats, like smallpox. He addresses the many challenges faced by the (now) real possibility of reintroduction of smallpox vaccinations and the sundry inherent controversies we are now hearing about: vaccine shortages, high-risk priorities, stockpiling, adverse reactions in a greatly enlarged and immunologically compromised community.

By now, most health professionals can tick off on their fingers the more likely biological terrorist threats -- anthrax, plague, tularemia, Q fever, staphyloenterotoxicosis, botulinum toxin, ricin, smallpox, the hemorrhagic fever viruses, etc. With 2 exceptions -- smallpox and plague -- these infections and intoxications have meager historical provenances. As he has done with smallpox (expertly focusing on a singular disease), one would hope Tucker will focus future efforts on updating the rich but dated history of bubonic plague.[10] (Yersinia pestis is the only other ancient and possible future scourge we may still have to face.)

Tucker refers to biological warfare as "public health in reverse"[11] -- which indeed it is. As writer Laurie Garrett has gloomily suggested,[7] the world's public health initiatives are stalled, and are in need of major repair. Others have suggested that a malevolent hand may be wrenching its gears into reverse. If airplanes and airmail can be terrorist weapons, why not the public health flip card, bioterrorism?

Fortunately, Dr. Tucker is a bit more optimistic. He ends his work with a simple statement: "the eradication of smallpox will remain as much a cautionary tale as an inspirational one."[12]

A similar statement could be said of his book. It is both cautionary and inspirational.

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