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Smallpox: From Public Health Victory to Public Health Threat Commencement Address: Arnold School of Public Health

May 9, 2002

Dean Pastides, members of the faculty, graduates, family and friends, it is a great honor for me to join you today. As a former dean of a school of public health, I am delighted to welcome this class of graduates into our profession. It is a noble calling and you are entering the field at a time of great challenge and opportunity.

My greetings today also come from a second perspective – that of a friend of your school. Dean Pastides and I have been colleagues and collaborators for many years – long before our career pathways brought us both to South Carolina. I have watched the rise of the Arnold School of Public Health under his leadership with a sense of pride and admiration. Indeed, you are very lucky to have him as your dean, just as you are fortunate to have Norman Arnold as the patron saint of this school. Mr. Arnold’s vision for improving the health of South Carolinians places responsibilities on both of our institutions and challenges us to work together more effectively. It is in that spirit that I dedicate my remarks today to Norman Arnold and call for our schools to form a lasting partnership.

Commencement this year is quite unlike any other in the history of public health. You are the first class of public health graduates in the United States for whom the term "bioterrorism" is not a theoretical construct, but a painful reality. The terrorist attacks on September 11 and the mailing of five letters containing Bacillus anthracis, whether connected or unrelated, made evident several facts. First, there are persons who are willing to inflict mass casualties upon the general population. These individuals will use any means available to them to inflict injuries and death. We also learned that organisms that can be used for bioterrorism are frighteningly accessible in this country and abroad. Moreover, we discovered that commonplace vehicles, such as the mail system, could be used to deliver these organisms to their targets. Finally, we realized that we were ill prepared to anticipate, detect, and respond to such attacks.

Admittedly, the five letters bearing Bacillus anthracis had a limited impact in terms of morbidity and mortality. Fortunately, only five deaths occurred – a small toll compared with the almost 3,000 deaths at the site of the World Trade Center. Nevertheless, those who carried out the attack with anthrax demonstrated that they could disrupt the very fabric of our lives. For months, emergency responders and public health departments across the country were besieged with concerns about "suspicious" white powders. Millions, if not billions, of dollars were spent on investigating these substances, governmental office buildings were shut down, and mail delivery was disrupted. The postal service, which prided itself on being deterred by "neither snow, nor rain, nor heat, nor gloom of night," met its match in a handful of letters laced with microbial agents.
The anthrax episode demonstrated that even limited acts of bioterrorism could produce mass anxiety. The run on prescriptions for ciprofloxacin, gas masks and other personal protective devices clearly demonstrated the widespread fear among our fellow citizens. These fears will be resurrected if and when another attack occurs. Our leaders assure us that the question is not whether another bioterrorism attack will occur, but rather when it will happen.

This prediction is a grim forecast for those of us in the public health profession. As if we did not already have our hands full with the burden of naturally occurring diseases, now we must also be prepared for those that are unnaturally unleashed by humankind. If there is a silver lining in this cloud, it is that the public health infrastructure may finally get the attention and resources that it deserves.

Already a billion dollars of new funding has been allocated to address these needs, with the promise of more to come. In preparing for bioterrorism, the Centers for Disease Control and Prevention identified a series of biological agents that should receive the highest priority. This group, collectively referred to as Category A organisms, are deemed to pose the greatest risk to national security.

The Category A agents include those responsible for causing anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers. For the purposes of this talk, I would like to focus on smallpox because it holds a special place in the annals of public health.

Smallpox is acquired by inhaling the causative agent – variola virus – via contaminated air particles or aerosols. Exposure to just a few virions can cause infection. After an incubation period of about two weeks, the host develops fever and chills and becomes debilitated. A few days later, a characteristic skin rash appears on the extremities or the face, beginning as raised red spots that become fluid filled, and later crust over creating the pocks for which the disease is named. There is no known effective treatment, although studies are underway on various antiviral agents. The severity of illness varies widely, with the risk of death ranging from 1 to 30% of infected persons. Those who survive an infection have lasting immunity to the disease.

Although it is uncertain when smallpox first emerged, there is evidence from Egyptian mummies that it was present more than three thousand years ago. A famed Persian scholar, Rhazes, made the first recorded description of this disease in the tenth century. It seems more than a little ironic that the modern day countries in this same region, Iran and Iraq, are among the handful of nations thought to be harboring stockpiles of smallpox to use against their enemies.

One of the most dramatic aspects of the story of smallpox is the role that it played in the Spanish conquest of the Americas. In 1518, just 26 years after Columbus first traveled to the New World, smallpox was introduced into Hispaniola, site of present-day Haiti and the Dominican Republic. As the Native American population had never been exposed to smallpox and had no immunity, this epidemic resulted in the deaths of virtually all of the 3.5 million inhabitants.

From Hispaniola, smallpox traveled to Mexico where the conquistador Cortes and a force of 600 men were able to defeat an Aztec population that numbered in the many millions. As survivors of earlier outbreaks in Europe, the invaders tended to be immune to smallpox, whereas the Aztecs had no prior exposure and therefore were completely susceptible.

In his book Guns, Germs, and Steel, author Jared Diamond writes that: "Far more Native Americans died in bed from Eurasian germs than on the battlefield from European guns and swords." He goes on to add that: "Aztec survivors were demoralized by the mysterious illness that killed Indians and spared Spaniards, as if advertising the Spaniard’s invincibility."
Of course, the invading Spaniards were the inadvertent beneficiaries of the effects of smallpox on their adversaries. The first intentional use of a biological agent for military purposes also involved smallpox, and occurred during the French and Indian wars. In 1763, British forces distributed to Native American tribes blankets that had been used by smallpox patients. As it was known that infection could be spread through contaminated bedding, the objective clearly was to disseminate infections to their previously unexposed foes. It has been estimated that the targeted Native Americans suffered a mortality rate of over 50 percent.

At roughly the same time that the British were experimenting with smallpox as a weapon, elsewhere they were exploring methods to prevent infection. They were not the first to do so, as the technique of variolation had been developed earlier in the Mediterranean region. This procedure involved removing fluid from the skin lesions of a person infected with smallpox and placing this material within an incision in an uninfected person. An illness would arise in the inoculated person, but it would be less severe than one acquired naturally. The practice was introduced into British society when Lady Mary Montagu, wife of the English ambassador to Turkey, had variolation performed on her son. Princess Caroline had her two sons inoculated as well. Once the royal family endorsed variolation, it became fashionable among the British elite.

During the eighteenth century, variolation was even more widely adopted within the American colonies. Smallpox epidemics occurred periodically in the colonies and one such large-scale outbreak occurred in Charleston in 1738. That outbreak was traced to the slave ship, London Frigate, which arrived from Guinea with infected passengers who were not detected during the quarantine inspection. Although health statistics from this period were very rudimentary, some data from the 1738 epidemic were published at that time in the local newspaper. Almost 1,700 persons, roughly a quarter of the residents of Charleston, were diagnosed with smallpox during the outbreak. Over 300 deaths from smallpox were recorded during this epidemic. Interestingly enough, the case-fatality rates for slaves were lower than those for whites, regardless of inoculation status, probably because of natural immunity acquired from childhood infections.

While variolation reduced the mortality from smallpox, the procedure had many detractors. Some opposed it on religious grounds, others objected to it because serious illness could arise among inoculated persons and even if their illness was not severe, they could spread smallpox to those who were not inoculated. These concerns set the stage for the landmark work of Edward Jenner at the close of the eighteenth century.

Jenner, a country physician in England, was aware of the belief among farmers that persons who had the mild disease cowpox were protected from acquiring smallpox. Cowpox is a viral illness that can be transmitted from infected cows to humans who milk the cows. In May of 1796, Jenner transferred material from the hand of a dairymaid infected with cowpox to an eight-year-old boy. When later challenged with a smallpox inoculation, the boy demonstrated immunity.
Thus, the principal of vaccination was born. Interestingly enough, when Jenner submitted his observations in a paper to the Royal Society of Medicine in 1796, the paper was refused. Fortunately, Jenner was persistent and published his observations in a book, which now stands as a medical classic. Less than a decade later, Thomas Jefferson wrote to Jenner making the following bold claim: "Future nations will know by history only that the loathsome smallpox has existed and by you has been extirpated."

As usual, Jefferson was correct, but his prophecy would not be fulfilled for the better part of two centuries. In 1966, smallpox still was responsible for an estimated 10 to 15 million deaths around the world. The following year, the World Health Organization undertook a program to eradicate smallpox through vaccination in endemic areas. The last recorded naturally occurring case was diagnosed in Somalia a decade later and in 1980, smallpox was declared eradicated.
The campaign against smallpox stands as one of, if not the greatest, triumph of public health. It was the first time that a disease of humans was eliminated through human intervention. To do so required global cooperation. The peoples of the Northern Hemisphere, whose ancestors inadvertently spread smallpox throughout the world, worked in cooperation with those of the Southern Hemisphere to banish this dread disease.

It is a tragic irony that this success story might now have an epilogue in which smallpox is reintroduced intentionally by humans in order to inflict pain and suffering on others. Since vaccination was terminated in this country almost thirty years ago, half of our population has never been vaccinated. Even those who were vaccinated probably have little remaining protection. Therefore, we are as susceptible today to the devastating effects of this disease as were the Aztecs and the Incas five hundred years ago. In light of this vulnerability, the federal government is preparing a stockpile of smallpox vaccine that soon will be sufficient to cover every person in the United States.

The story of smallpox is a cautionary tale for the public health community. As scientific knowledge expands, it can be applied for constructive purposes, or just as easily for destructive ends. During the twentieth century, we witnessed the translation of advances in nuclear physics into weapons of mass destruction. In the twenty-first century, the advances of molecular biology may be subverted into weapons of unprecedented lethality.

How then shall those of us in the field of public health respond to this new emerging world of bioterrorism? First and foremost, we must recognize that such threats exist and develop plans to deal with them. We must secure the laboratory inventories of hazardous biological agents and limit accessibility to them. We must rebuild the public health infrastructure, so that the introduction of life-threatening organisms can be detected quickly and controlled effectively. We must assure that there are adequate supplies of vaccines and anti-infectives, and that these supplies can be delivered promptly to those who need them. We must promote the seamless interaction of local, state and federal public health agencies. We must coordinate with emergency medical teams and other first responders to assure that they have the proper training to handle casualties of biological agents. We must improve our public education and communication efforts to calm anxieties and prevent widespread panic. We must conduct research into the basic mechanisms of these agents in order to disarm them.

In other words, our response to bioterrorism calls upon all of the traditional roles of public health. Bioterrorism is not a diversion from our customary business, but rather a reinforcement of it. As we prepare to handle the biological agents of terror, we will build capacity to handle other threats to human health. In the end, the challenges that we face today will result in a public health system that is stronger, better organized, and more effective. Today’s graduates will play a critical role in that transformation, and with great expectations, we welcome you into the profession.

Again, let me offer my best wishes to all of the graduates, their families and friends. Thank you very much.