Why would you approve a drug for a disease that no longer exists? The simple answer is that the virus that causes the disease still exists, and if it got loose, it would be a weapon of unimaginable catastrophe. That is the rationale for the US Food and Drug Association’s certification of brincidofovir (Temvexa), a potential treatment for smallpox.
Medical science had once thought it was done with smallpox. It is the only disease ever eradicated in nature, and the last of its virus, variola, sits frozen in secure laboratories and no longer exists in nature.
I tracked down the last human to be naturally infected with the disease that killed or blinded hundreds of millions of people, the disease that scarred the face of Elizabeth I of England, that decimated the Aztec empire and indigenous people in the New World, and that once was worshipped as a Hindu god.
By 1979, the World Health Organization (WHO) had trapped the smallpox virus to a small area on the East African coast. The technique that had succeeded in this battle was simple: Create an intelligence system that hunted for cases, and when a case was found, pour in vaccinators to vaccinate every contact of those cases. Pay a finder’s fee to the person reporting the case. Trying to vaccinate everyone in the developed world was inefficient and unnecessary, but focusing on vaccinating contacts worked.
Smallpox had been eradicated everywhere, even India, where it was once worshipped. One day, WHO discovered there was only one case left in the world, in Somalia, a young man who survived a relatively mild case.
I had to go meet him. That presented problems.
I was a science reporter for the Philadelphia Inquirer and I was writing a book on smallpox, which is to this day the only disease that has been entirely eradicated. Somalia was and is a benighted country on the coast of the Indian Ocean. The government then called itself the Somali Democratic Republic, and they did not allow journalists in. No American reporter had been there in years.
That left the problem of journalism ethics. Journalists are never supposed to conceal the fact they are journalists, and if I went, it would be under false pretenses. I rationalized that it was the only way I could get the story, and the story was unusually important. If I got caught, I would likely end up in a Somali prison. Or worse.
I told this to a supportive WHO administrator in Geneva, and he arranged for me to get an ID identifying me as a WHO investigator, something he wasn’t supposed to do. Apparently even the hidebound WHO bureaucracy wanted their story told.
The problem was solved by an Inquirer intern who was traveling with me. She was in charge of going through the mountain of paper generated by the bureaucracy, something that would have bogged me down forever. One night in Delhi, where we had gone to do research, she went to the hotel bar for a drink. She was an attractive woman, tall, young, redheaded, and not shy, and she immediately attracted the attention of two young men, who chatted her up. She found out that one of the young men was the nephew of the Somali ambassador to India, and the next morning I got my visa. Charm won. Two weeks later, a beat-up Somali Airlines Boeing 720 took me from Cairo to Mogadishu by way of Ethiopia. Since Ethiopia and Somalia were at war at the time, I kept looking out the window, waiting for rocket flashes.
The country was a dystopian disaster from generations of civil war and terrorism. Many buildings were wrecks, and food was scarce. Since parts of Somalia were Italian colonies before World War II, I assumed I would at least get a decent Italian meal. No such luck. The main entertainment ― trying to keep the monkeys from stealing my sandwiches while lunching at a beach bar.
Another helpful WHO investigator, a Czech, Zdeno Jezek, took me to Merka, an ancient port southeast of the capital to meet Ali Maow Maalin.
Maow was a cook at a hospital outside of Merka in April of 1977, and he was the only employee there when a family of four, including two children, were brought in. He told me he put the family in a Land Rover and drove them to an isolation camp outside of town. He had not been vaccinated, but he said the children did not look very sick and he wasn’t worried. One of the children, a little girl, died a few days later.
Maow said he was in contact with the family for total of perhaps 15 minutes. When he got sick a few days later, with a high fever, pain in his joints, and vomiting, doctors diagnosed chickenpox, which looks something like smallpox and presents some of the same symptoms. It was a common misdiagnosis. Maow had seen the photos of smallpox victims, and when a rash broke out, he knew exactly what it was. He tried to keep it a secret, but a few days later, a friend saw him and reported him to the WHO network and gathered a reward. Maow was placed under guard and eventually transported back to the hospital, where bedlam broke out.
The hospital was shut down and all the patients were removed. No one was allowed to leave the hospital without being checked for a smallpox vaccine scar. Blockades were placed across the roads. Vaccinators from elsewhere were rushed to the scene as WHO waited for the seemingly inevitable secondary infections. They vaccinated 54,777 people.
The secondary infections never came. Ali Maow Maalin was the last human to catch smallpox as the result of a natural infection.
But he was not the last to be infected with variola. A year later, Ann Algeo, a patient at a London hospital, became ill and was eventually diagnosed with smallpox. She was placed in a bed next to a woman named Norah Hurley. Mrs Hurley was visited regularly by her son and daughter-in-law, and days later, both got sick and died. It was clearly a leak from the hospital lab where people were working with variola. It was also clear smallpox was loose in the land. Every possible contact was traced.
Ten months after Maow’s infection, Janet Parker, 40, a lab photographer in Birmingham, fell ill. Her office at the Birmingham University Medical School was one floor up from a virology lab that also stored samples of variola in a hallway freezer. She had been vaccinated 10 years earlier, but she too fell ill, and she died on September 11, 1978, the last human to die of smallpox. Henry Bedson, the director of the lab, committed suicide. Parker’s mother died of a heart attack. Britain got rid of all its variola samples.
The only remaining samples of variola now are in a freezer in the CDC headquarters in Atlanta and in a Russian laboratory. Little is known about the Russian sample, but the CDC sample is kept in a high-security facility.
The two samples could be easily destroyed, but scientists want some around in case terrorists get some and turn it into a weapon, hence the work on a treatment. All you would need to do is to infect one person with the disease and put him or her on an airplane to ― say ― New York City, and an unvaccinated America would face catastrophe. Now we may have a treatment to offer.
Maow? He died of malaria 2 years later.
Shurkin was a national reporter for Reuters in New York and covered the space program. He was science editor at the Philadelphia Inquirer and science writer and instructor in science journalism at Stanford University, University of California Santa Cruz and the University of Alaska Fairbanks. He was part of the team that won a Pulitzer Prize at the Inquirer. He is the author of 10 books on science and the history of science.
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