The End of a Global Pox: America and the Eradication of Smallpox in the Cold War Era by Bob H. Reinhardt (review)

For thirty-five years, mentioning a lesson from smallpox eradication has sometimes been followed by, “But smallpox eradication was easy.” This book provides a more factual account. The author has done an amazingly detailed review of documents and related materials on the program origins.

He gives deserved credit to the Soviet Union for promoting the program and highlights early resistance from the United States. When first proposed in 1953 by WHO, only France, Uruguay, and Panama supported the idea. The United States argued it was too difficult. So, the World Health Assembly (WHA) voted to undertake malaria eradication!When finally accepted, in May 1965, by the WHA, the United States changed its opposition to become a strong supporter and funded, through USAID, a program administered by CDC, to eliminate smallpox in nineteen African countries. The five-year goal was met in three and a half years, under budget, to become a model for other countries.

The author provides a rich litany of the many barriers, from the virus itself to social factors, climatic impediments, communication and transportation challenges, and no end of political obstacles stretching from USAID through national and local African structures. But it was done! Surgeon General Julius Richmond said, “Those CDC workers were too young to know they couldn’t do it.”

The author goes through the campaign in Asia, Brazil, and East Africa to the messy aftermath: unintended consequences, such as the retention of smallpox virus in the United States and Russia because of mistrust. Even worse was the violation of trust by the Soviet Union, producing tons of smallpox virus, after eradication, for weapons of bioterrorism. This unbelievable betrayal was not the work of the Soviets we worked with and respected but of a leadership seeking power at any cost. While the virus should be destroyed, this act, plus the inability to account for all virus produced, is of far greater concern.

I recommend this book for the lessons of smallpox and other organisms of great threat. While I applaud the book, and admit the author may be correct, I would question some conclusions.

1.) Coercion did occur but reflects the frustration of workers, not scientific necessity. Surrounding recalcitrant people with vaccinated persons would stop an outbreak. 2.) The author repeatedly sees the program as the result of a liberal 1960s movement in the United States. Perhaps, but the origins may have been public demand for government action when the polio vaccine was shown to be effective in 1955. President Eisenhower asked Secretary Hobby (absolutely opposed to any socialized medicine) to develop a government plan to purchase vaccine. Vaccines went from the protection of individuals to the protection of individuals and society. Ten years later the same reasoning went global with U.S. support for smallpox eradication. 3.) The author sees variolation (p. 107) as “the most extreme challenge.” While the practice could start smallpox outbreaks, our strength was finding and stopping outbreaks. Under rare circumstances the virus could be kept viable for long periods, but variolation could not have continued for long after an area became free of clinical cases. 4.) Despite concentration on smallpox, the measles program was very impactful and Gambia demonstrated the possibility of interrupting measles under African conditions. It was of short duration because USAID stopped funds. To withdraw measles funds after five years, before countries could arrange their own purchase of vaccine, was international assistance malpractice! 5.) The author does not mention the July 1967 meeting of smallpox workers in Accra, Ghana, when surveillance/containment was first presented on the basis of experience in eastern Nigeria. 6.) Finally, one statement will be regarded as offensive to most smallpox workers. The author (p. 84) says, “Like the jet injectors used and the disease targeted by the program, its metrics bore...