On October 13, 1977, a government health worker in Somalia found a nomad family desperately ill. Among the victims were two children. The worker, not knowing what else to do with the family, put them in his Land Rover and took them to a hospital in Merka, south of Mogadishu. No one at the hospital knew what to do either, but a hospital cook, 23-year-old Ali Maow Maalin, did. He jumped in the Land Rover and drove the children off to an isolation center. Nine days later, Maalin came down with smallpox.

He survived, history's last naturally infected smallpox patient.

In 1980, the World Health Organization, which had battled smallpox all over the world for decades, declared the disease eradicated, the first and only human disease to be totally eliminated. The virus, with the deceptively innocent name of variola, is extinct in nature. The only remaining virus stocks exist deeply frozen in two high-security laboratories, one at the Centers for Disease Control (CDC) in Atlanta, Georgia, the other at Vector, the Russian facility in Novosibirsk. We think.

Last week, the Clinton administration, against the adamant objections of most countries and much of the scientific community, decided not to destroy the U.S. store of virus, as had been planned. The decision infuriated the rest of the world and raised many questions, some of which have gone unasked, not to mention unanswered.

It is impossible to exaggerate the awfulness of smallpox or its place in history. It was one of the deadliest and most disfiguring of all human ailments. In some places, smallpox was 90 percent fatal. Death by smallpox was particularly horrible. Survivors could spend the rest of their lives with vision clouded or lost forever, with deep ugly scars across their bodies reminding them the time they spent in the shadow of death.

Smallpox broke the siege of Mecca in 568 C.E. Smallpox is the reason Queen Elizabeth I wore heavy white makeup and wigs. India has a goddess of smallpox, Sitala, so significant was the disease there. It was smallpox, not Cortes' army, that destroyed the Aztec Empire at Tenochitlán. He actually lost the battle, only to have the virus win the war for him. American settlers, though not completely clear on the science, took blankets that had covered smallpox patients and deliberately sent them to the Indians as gifts, hoping to infect them. It often worked, literally decimating entire tribes including the Mandan, Assiniboin, and Blackfeet.

Smallpox has no cure. A smallpox victim now would suffer almost the same fate as a victim in the 13th century, although antibiotics would treat some secondary infections, and modern medicine could make the patient more comfortable. The mortality rate would be about the same. It will either kill you or it won't.

But smallpox itself was vulnerable. In 1796, the English physician Edward Jenner infected an eight-year-old boy, James Phipps, with material taken from cowpox sores on the hand of Sarah Nelmes, a milkmaid. Jenner had noted that milkmaids, who frequently caught an annoying but nonfatal disease from their cows, rarely caught smallpox. After Phipps recovered from the cowpox, Jenner deliberately infected him with smallpox. He was immune and lived to a ripe old age. Jenner had produced the world's first vaccine.

Before Jenner, many people deliberately infected themselves with a mild case of smallpox to obtain immunity, a practice called variolation. They hoped they would get a less than lethal dose, and usually did. The mortality rate was less than 2 percent as opposed to the 20 percent from natural smallpox. Use of the vaccine, however, eventually spread around the developed world, brought to the United States by Thomas Jefferson. Tamed in Europe and the America, smallpox still ravaged the rest of humanity.

The cowpox virus, called vaccinia, is a cousin to variola, and produces almost complete immunity from smallpox. Vaccinia mutated some time in the past, probably contaminated by variola. The vaccinia in smallpox vaccine is an unnatural hybrid. The disease also was vulnerable because it has no animal host. It infects only humans. Unlike polio, for instance, it can't hide in animals and return later to strike people.

Scientists attacked the disease at those weaknesses. They developed a freeze-dried vaccine that could be stored and taken anywhere. Drug company researcher Benjamin Rubin invented a bifurcated needle that made giving the vaccine easy and painless. The World Health Organization devised tactics to end the spread of the disease, and finally cornered it in Somalia in 1980. According to plan, the last remaining stores of smallpox virus were to be incinerated on June 30, 1999, and variola would be extinct. Now that probably will not happen because of the decision by President Clinton.

Why keep samples of some of the world's deadliest organisms alive? Virtually every health and scientific organization, including the World Health Assembly, has urged the virus be killed. A poll of 79 countries showed that only one, Russia, wanted the virus preserved; four, including the United States, the United Kingdom, Italy, and France, were unsure, and 74 wanted the virus exterminated. The 74 included the rest of Europe and most of the developing world, which had suffered most from smallpox and contributed most to its eradication. So why go against that advice?

According to Donald A. Henderson, who headed the WHO smallpox eradication program and is now head of the Johns Hopkins Center for Civilian Biodefense Studies, the White House was getting pressure from two groups. One consisted of basic researchers who thought there might be something still to learn from the virus.

Smallpox was eradicated before the development of modern microbiological techniques, and we don't know it as well as we know many other viruses. For instance, it infects only humans - and that's true of almost no other virus - so it might tell us something about the human immune system. Studies of the virus might help produce more effective antiviral agents or more effective vaccines. The vaccine we have now would be dangerous to people with damaged immune systems, such as AIDS patients.

A recent report by the Institute of Medicine of the U.S. National Academy of Sciences supports this scientific argument, although it takes no position on preserving the virus. The Institute decided that the most compelling argument for saving the virus was the possibility of creating more effective antiviral agents in case of biological attack.

The second source of pressure to preserve the virus comes from the U.S. Department of Defense, worried that terrorists will get their hands on the virus and use it as a weapon. Having the virus handy might help fight the spreading epidemic.

Henderson, and apparently most scientists - especially those who know smallpox best - find the researchers' argument uncompelling. The virus is so lethal it can only be studied in the highest security labs, and there are only two in the United States. Nonetheless, several strains have already been sequenced, and there are likely few mysteries of importance left.

Whatever insights that might come from studying variola can be addressed in other ways, he says. Henderson points out that monkey pox, which is almost indistinguishable from smallpox, is still available as a scientific tool. It is just as deadly, if much less contagious. Monkeys already serve as a natural model for monkey pox.

Moreover, the chances of finding an antiviral drug from smallpox are practically nil, he says. The virus quickly spreads to every cell of the body, collecting in pustules and boils, and the chances that anything would work against that are minimal.

Improving on the vaccine seems implausible and unnecessary. Smallpox vaccine already is among the most effective vaccines ever created. Developing a new one could cost half a billion dollars, and there is no market.

The best argument comes from the defense establishment. Russian sources have hinted that the virus is no longer contained solely in Vector, and may even have been given to terrorist countries, especially North Korea. Lev Sandakhchiev, director of the lab, strenuously denies that. However, Vector itself, once a state-of-the-art biological research center, has deteriorated along with much of the Russian infrastructure and can no longer be trusted, some U.S. officials feel. Neither, they say, can the Russians manning the facility. Administration officials say to destroy the virus, with that threat hanging over our heads, would be irresponsible.

The weakness in this argument is that having the virus handy would be of little help in case of an attack. The vaccine is made of vaccinia, not variola, and having the virus around will not help build up stores of vaccine. WHO left seeds of vaccinia around the world in case it was needed, and vaccine would be developed from that. Moreover, whatever you develop would have to be manufactured and distributed within a matter of weeks after an attack, which can't be done.

Henderson says we probably can't know where all the virus is. Iraq's biological warfare abilities were at first thought to have been eliminated, yet later not so. "What if someone decides on a terrorist campaign with the virus, or North Korea equips a missile warhead with variola?"

Putting it bluntly, if anyone does use smallpox as a weapon, there is very little that can be done about it. The United States currently has enough vaccine stored away for 6-7 million doses and it would take as long as three years to build up stocks sufficiently to block an epidemic, which would be much too late. Only one company, Wyeth, currently makes vaccine for the military. Most Americans under the age of 30 have never been vaccinated, and those who have been vaccinated may no longer have total immunity. The effects of smallpox loose on an unvaccinated population are the stuff of nightmares.

Then there is the risk of just having it around. Ali Maow Maalin was described as the "last naturally infected" smallpox patient because ten months after his illness, variola got loose in St. Mary's Hospital in London, and two people died. Officials blamed lax laboratory techniques. The lab was one of five repositories of smallpox virus then in the United Kingdom. In August 1978, it happened again, at the Birmingham University School of Medicine. A laboratory photographer, Janet Parker, died, and the virologist in charge of the laboratory committed suicide. The British promptly got rid of their supply of virus. Parker is the last known direct victim of smallpox.

No one doubts the ability of CDC to keep its stock of variola safely. Many people doubt Vector's ability to do the same. Is keeping any of it worth the risk? Why keep it, then? Shortly after the eradication, John H. Richardson, director of biosafety at CDC, said, "The only reason to have smallpox virus is for offensive [biological warfare] purposes." Then again, it could be used in retaliation for a biological attack. Now that's scary.

Joel Shurkin is a staff writer for HMS Beagle. He is also author of The Invisible Fire: The Story of Mankind's Triumph over the Ancient Scourge of Smallpox (1979, Putnam).

Andrzej Krauze is an illustrator, poster maker, cartoonist, and painter who illustrates regularly for HMS Beagle, The Guardian, The Sunday Telegraph, Bookseller, and New Statesman.

---

Tell us what you think.

Endlinks

Smallpox: The Triumph over the Most Terrible of the Ministers of Death - detailed article from October 15, 1997 issue of Annals of Internal Medicine, rich in citations.

Bioarmageddon - one of a series of bioterrorism special reports. From the September 19, 1998 issue of New Scientist.

The Remaining Smallpox Virus Stocks Are Too Valuable to Be Destroyed - editorial from the December 9, 1996 issue of The Scientist, not long after WHO first made its decision.

Poxviruses - online course notes from a virology course at Leicester University, covering the taxonomy, structure, and life cycle of vaccinia and variola viruses.

The Smallpox Dilemma - a recent ABC News feature, including comments from Donald Henderson.