The Life and Death of Smallpox (review)

Smallpox is a disease whose time has come and gone and then come back yet again. From the official declaration of eradication in 1979 to the mid-1990s, study of and reflection on the disease was largely limited to medical historians and a few virologists. With increasing concern about potential bioterrorist agents, smallpox included, and the recurrent rumors and anecdotes of potential unaccounted-for caches of the lethal virus, the press and the public, public health researchers and government officials, intelligence agencies and pharmaceutical manufacturers have all developed a renewed interest in this pathogen.

The Life and Death of Smallpox provides a relatively pithy primer on the biology and history of both the disease and the vaccine. It is clearly written and contains considerable information. The general reader looking for an overview might turn here and gain some insights. However, the authors seem to have relied on a small number of oft-referenced sources; they only superficially address some key policy issues and recent events; and they offer no new insights about them. For the reader interested in the history of smallpox, it is best to seek Donald Hopkins's book The Greatest Killer.¹ For the clinical aspects of smallpox, the disease, see C. W. Dixon's text, Smallpox.² For details of the eradication effort, see the series of country-specific volumes produced by the World Health Organization. For consideration of more recent smallpox vaccination policy, see the report of an Institute of Medicine committee, The Smallpox Vaccination Program.³

The first several chapters cover the histories of first the disease and then the discovery and dissemination of vaccination. The chapters are organized chronologically, and within each era they address events and individuals in many parts of the world. Thus, the reader is taken from England to Scotland to France to New Zealand to the Crimea to the U.S. Civil War within two pages in chapter 10. The resulting narrative is filled with information, and because there is no easy way to present such multinational, multimillennial material, the reader may occasionally feel a bit jet-lagged.

One attribute of this book is its more extensive coverage of smallpox and vaccination in England. There are many interesting anecdotes and facts—from references to smallpox in the works of great British novelists, to learning that Josiah Wedgwood (of pottery fame) was the grandfather of Charles Darwin. But some interesting and relevant historical elements are not included. George Washington is mentioned as having "an acute awareness of the danger of inoculated smallpox" (p. 88), for example, but there is no mention that his face was pockmarked due to an infection acquired in Barbados in 1751.

Chapters on the recent history of the eradication effort and on the issues of smallpox and bioterrorism suffer from a reliance on limited sources (the IOM report is not referenced) and a lack of critical analysis. Many individuals who played critical roles in smallpox eradication have been ignored or undervalued. In the late 1960s and early 1970s David Sencer, the director of the then Communicable Disease Center, made key decisions in resource allocation and prioritization that provided crucial support to the global effort. The role of the U.S. Agency for International Development is not discussed. The authors do not mention that the WHO during the smallpox eradication campaign used as a justification for the program their belief that this agent was very unlikely to be used for bioterrorism. In addition, the story of eradication could be considerably enhanced by including more of the perspectives of the local participants in programs for which most of the histories have been provided by a few international participants. Such a book has yet to be written.

The discussion of recent smallpox-vaccination policy decisions also suffers from little political context. The IOM committee report questioned the scientific credibility of the promulgated policy. The role of the USSR in advocating early for the eradication of smallpox and then later stockpiling...