Welcome to Stuff You Missed in History Class, a production of I Heart Radio. Hello, and welcome to the podcast. I'm Tracy V. Wilson and I'm Holly Fry. Late March of last year, I researched and wrote our episode on the eradication of render pest because in that moment, it just felt really weird to me to work on episodes that were not about the pandemic somehow, because that was dominating everything in our lives. But at the same time, I wanted to work on something that felt kind of optimistic because the pandemic was dominating our lives. Uh So, now it's almost a year and a half later here in the US, we had a pretty hopeful springtime regarding the progress of the pandemic. I know that was not the case in the whole world, but we had what was looking like improved situations that obviously has taken a turn once again for the worst, or at least the worst, maybe not the worst of ever, but definitely worse. I wanted to kind of return to the idea of wiping a disease off the face of the earth. So render pest and smallpox are the only two diseases that have been eradicated through human activity. Neither one of them is technically extinct, because there are some samples of both viruses that still exist in labs. They're no longer circulating out in the wild, though. And we've talked about smallpox a bit on the show before. We had our episode on Edward Jenner and the smallpox vaccine and how the vaccine was developed and then generous efforts to try to make it more widely available. More recently, we did the episode on the Royal Philanthropic Vaccine Expedition, and that was all about Spain's efforts to transport the smallpox vaccine to the America's which required a chain of living hum and hosts. We mentioned pretty briefly the eradication of smallpox and both of those episodes, but we have not gone into detail about how that happened. That's what we're going to talk about today. And when Tracy mentioned it to me, I said, we've covered that. No, it just keeps coming up. It just keeps coming up. We've said in like a sentence how it was done, but it's a more than a sentence worth of explanation. Yeah, it's just it's a it's been just peppered in enough that my brain was like, yeah, that that was an episode, right, No, Nope. So smallpox is a viral disease that has existed for millennia when it was circulating in the wild. It's spread from person to person through the air, usually through face to face contact, and it can also be spread through contact with contaminated objects and surfaces. People who contracted smallpox typically developed a high fever and body aches, and that was followed by a distinctive rash. There are two different strains of the very Ola virus that were causing smallpox, very il a major and verial a minor. As that name suggests, very el a major caused more serious illnesses. As many as a third of people who were infected with very Ola major died, as many as nine of babies died. It was also particularly lethal any time it was introduced somewhere that it hadn't existed before, such as when Europeans started arriving in the Americas, and in those cases, smallpox usually killed about half the people who contracted it Among the people who survived the disease. Smallpox could also be both disabling and disfiguring. There was and is no cure for smallpox, so even as science and medicine progressed, it continued to be deadly. But it also had some traits that made it a good candidate for a worldwide eradication campaign. Smallpox was easy to recognize and diagnose. Unlike say, the flu, which can resemble a lot of other respiratory infections, smallpox passed directly from person to person and only infected humans, so there were no hidden reservoirs of the virus that could potentially start a new outbreak. That's different from something like yellow fever, which also infects other primates and is transmitted by mosquitoes. Another plus, once a person had recovered from smallpox, they were immune for life. For a number of reasons, smallpox outbreaks also tended to develop relatively slowly. Once people were contagious, they were usually also too sick to really leave home, so outbreaks tended to cluster around members of the same household and their immediate neighborhood. And then once an outbreak was identified, swift action could keep it from spreading very far. And most importantly, there was a way to disrupt transmission of the disease in this case of vaccine in terms of the smallpox vaccine. At first, people prevented smallpox using a technique called variolation that involved intentionally introducing material from one person's smallpox sore or scab into another person. Practitioners in Asia were doing this as early as the eleventh century, and the technique spread from there. Then, in the late eighteenth century, people started to make a connection between smallpox and another much milder disease that was called cow pox. The smallpox and cow pox viruses are both in the genus orthopox virus, and people who had contracted cow pox seemed immune to smallpox. Several people, including Edward Jenner, tried deliberately exposing people to cow pox as a way to prevent smallpox. Jenner called this vaccination, after the Latin word for cow. So both variolation and vaccination could prevent smallpox, but since variolation could also cause full blown smallpox, vaccination was a lot safer. At the same time, though, vaccination in its earliest forms carried some of the same risks that variolation did, including the potential for transmitting other illnesses like syphilis and hepatitis from person to person. During these person to person vaccination chains. Sometime in the nineteenth century, people shifted from using cow pox to using vaccinia virus, which is another orthopox virus, to make smallpox vaccine. The origins of the vaccinia virus are unclear. It is possible that it's actually some kind of hybrid of cow pox and smallpox, or that it developed over time as cow pox virus was passed through multiple hosts in the process of making vaccines. Eventually, vaccinia virus replaced cow pox virus for vaccination purposes, just as vaccination with cowpox had previously replaced variolation with smallpox itself. At first, vaccines made with vaccinia virus were grown in the skin of live animals like calves, sheep, and rabbits. Eventually that shifted to growing the virus in tissue cultures or in chicken eggs. These methods replaced those arm to arm vaccination chains that we talked about in our episode on the Royal Philanthropic Vaccine Expedition. Countries actually started to outlaw arm to arm vaccinations in the late nineteenth century. Many of the vaccinia strains used to make vaccines were attenuated or weakened by repeatedly passing them through a non human host, things like chick embryo cells, eggs, or mice. This process resulted in a virus that produced an immune response when a person was vaccinated with it, but couldn't reproduce in that person's body and make them sick. So while vaccination with cowpox virus was safer than variolation with smallpox virus, vaccination with an attenuated version of vaccinia virus was also safer than vaccination with live, unattenuated cow pox. Yeah, there were still potentials for various complications, but this was an improvement overall. It really didn't take long after the development of vaccines for people to wonder whether vaccines could be used to eliminate smallpox entirely, but early attempts to do this faced a lot of obstacles. As we talked about in our episode on the Royal Philanthropic Vaccine Expedition, Early versions of smallpox vaccine lost their potency really quickly, especially in hot weather, and that continued to be true after vaccinia replaced cow pox as the preferred virus for smallpox vaccines. But then in the nineteen forties people started working on dehydrated and freeze dried versions of the vaccine. The Vaccine Institute in Paris produced a freeze dride vacuum packed vaccine that had a longer shelf life. In the nineteen fifties, Leslie Harold Collier at the Lister Institute study the preservation methods that were in use and how effective they were. In he developed a process that didn't require refrigeration, even in tropical temperatures. Once the vaccine was reconstituted, it still had a short shelf life, but until that point it could survive in the field for months. It also protected people from smallpox infection for at least ten years, and offered protection against dying of smallpox for some time after that. Callier's method eventually became the World Health Organization standard for vaccine used for the eradication campaign. Smallpox was eliminated in North America in nineteen fifty two and in Europe in nineteen fifty three, and that was done primarily through mass vaccination campaigns, especially once that were done in response to outbreaks. And this success came in spite of increasing resistance to vaccines and to compulsory vaccine programs and the United States. This resistance led to a Supreme Court case in nineteen o five, the city of Cambridge, Massachusetts, had been trying to stop a small pox outbreak and had ordered all adults to be vaccinated or to pay a five dollar fine. Henning Jakobsen refused to be vaccinated, and then, after being fined, he took the matter to court. In the words of the court's decision, quote, the liberty secured by the Constitution of the United States does not import an absolute right in each person to be at all times and in all circumstances, wholly freed from restraint. Nor is it an element in such liberty that one person or a minority of persons residing in any community and enjoying the benefits of local government, should have power to dominate the majority, when supported in their action by the authority of the state. It is within the police power of a state to enact a compulsory vaccination law, and it is for the legislature and not for the courts, to determine in the first instance, whether vaccination is or is not the best mode for the prevention of smallpox and the protection of the public health. We'll get some more on the campaign to eradicate smallpox and the rest of the world after a sponsor break. The World Health Organization's decision making body is called the World Health Assembly, and in nineteen fifty three, the w h A didn't consider smallpox to be a candidate for global eradication. It just wasn't a priority. But five years later a delegate to the w h A proposed a ten year eradication plan. That delegate was Professor Viktor Jdanoff, who was Deputy Health Minister of the Soviet Union, and this proposal included vaccine donations that would be provided by the USSR. But even with the promise of donated vaccines, this proposal still didn't pass. At the time, the World Health Organization was working on an anti malaria program and that was really just drawing most of the focus. In nineteen fifty nine, the Soviet Union's proposal was reintroduced, and this time it was passed as a voluntary global vaccine campaign. Countries where smallpox was endemic, that is, freely circulating, were asked to institute mass vaccine programs with a goal of vaccinating eight of their populations, and the countries where it wasn't, which were generally richer, were asked to contribute funding or vaccines towards the effort. At that point, smallpox was being reported in sixty three countries, and together those countries reported seventy seven thousand, five hundred fifty five cases of the disease. But it became obvious really fast that that number was way, way too low. For one thing, those sixty three countries only included the ones that were members of the World Health Organization, and some countries where smallpox was endemic were not members at that point, and that included China, which had a population of more than six hundred and sixty million people. But even in those sixty three countries, reporting was all over the place. In countries without a lot of public health infrastructure, smallpox cases weren't really being tracked. But even in places where that wasn't the case, sometimes the only smallpox infections being reported were the ones that ended up in hospitals. In reality, the countries or smallpox was still endemic in ninety nine were home to more than half the world's population, and that total number of annual cases was probably more like fifty million, not seventy seven thousand. This voluntary program was focused on national vaccine campaigns, and at least in theory, each nation's campaign would be tailored for its own culture, needs, resources, and infrastructure, but that also meant there was really no central strategy at work. The World Health Organization's role was mostly just making sure that there was enough vaccine available and providing assistance if nations asked for it. It wasn't really coordinating efforts. Are doing a lot of tracking and monitoring, and because under reporting of cases continued to be a huge problem, it was almost impossible to tell whether these national programs were even working. That made it much harder to secure funding or to rally support from nations that had already eradicated smallpox within their own borders, and for the most part, these early national campaigns were not working at least not very well. In many places, success was measured by how many vaccines were administered. Sometimes this led vaccinators to go after the easiest targets first, like vaccinating all the students at a school, but that meant that children in more outlying areas who were not attending school were not being vaccinated. Since there often weren't clear records, it wasn't unheard of for vaccinators to go back to the same school and vaccinate children again. Even though a successful smallpox vaccine typically left a recognizable scar be because of issues like this. At one point, India was reporting a vaccination rate of a hundred and forty because so many people were being vaccinated more than once. Things moved pretty slowly with all this for about five years, but then in nineteen sixty four, Dr Korrel Rashka of Czechoslovakia, who was a huge advocate of smallpox eradication, became Director of the Division of Communicable Diseases at the World Health Organization. In nineteen sixty five, the World Health Organization established a dedicated smallpox eradication unit, and that same year President Lyndon Johnson announced that the United States would start supporting the global smallpox eradication program. Soon, the US was supporting the work of the Pan American Health Organization in South America and also funding major vaccine efforts in Western and Central Africa. These years also saw improvements in how smallpox vaccines were administered. Most vaccines that people receive today are administered as shots. They go into the muscle or the subcutaneous skin layer using a needle, but smallpox vaccine goes into the skins superficial layers by the mid nineteen sixties. There were a few different methods for doing this. One was to scratch a person's skin with a needle or lancet, and another was to repeatedly press the tip of the needle into a person's skin. Neither of these methods was very precise. Depending on how skilled the vaccinator was, they might press the needle too far into the skin or not far enough. The amount of vaccine on the needle usually depended on things like how deeply it had been inserted into the vaccine bile. Excess vaccine was often left behind on a person's skin and left to either dry there or be wiped away. Kind of wasteful. It's so fascinating to me to think about this when I think most of the vaccines I've received are like those pre measured very carefully, like you open the uh dose and that's it. Yeah. So the margin for error of it is a little bit mind boggling. Yeah. And there are for sure vaccines that are not administered with shots at this point, but the shots, at least here in the US, are the majority of them. The standard Yeah, jet injector devices were made to try to address some of this and to make vaccinating more efficient. In theory, these could vaccinate one thousand people an hour, but in practice they were limited. Some required electricity to work, and others were operated with a foot pedal that was clunky, so these were only really practical in places where you could bring huge groups of people to one location to be vaccinated. Plus, these devices were expensive, and they were hard to clean, and they were prone to breaking down. But then Dr Benjamin A. Ruben developed the bifurcated needle, which was patented in July of nine. This was a simple needle and when it was started into a vaccine vial, it picked up one measured dose of liquid in between the two prongs. The prongs themselves were designed to keep the needle at the correct angle and depth with a person's skin, and the two pronged structure meant that it needed fewer presses into the skin to administer each vaccine. This made everything way more efficient. One vial of vaccine could be used to vaccinate four times as many people, and people could be trained to administer the vaccine with the bifurcated needle in about fifteen minutes, even if they had no previous medical experience. Plus, the bifurcated needles were cheap to produce, although they were originally intended to be disposable at the World Health Organization's request, they were made from a steel alloy, they could hold up to boiling or flaming. They could be sterilized and reused over and over before they started to dull. Boilable containers were designed so that vaccinators could drop used needles into the container as they went and boiled the whole thing at the end of a shift. Also, it was standard practice to clean a person's arm with paths that were soaked in alcohol or soap before giving them the vaccine. I know every time I've gotten a shot, there's been a little alcohol wiped down on the injection site. But studies had suggested that this wasn't actually removing bacteria or other contaminants, it was just sort of moving things around. Studies confirmed that the number of complications and secondary infections after smallpox vaccination was the same regardless of whether the vaccine site was wiped down beforehand or not, so most vaccination programs, especially in like more impoverished areas, dropped this step, and together all of this brought the cost for smallpox vaccination down to about ten cents a person. By nineteen sixty six, smallpox was endemic in thirty one country piece. That was down from the sixty three or more reported back in nineteen fifty nine. The number of estimated worldwide cases had dropped from about fifty million to somewhere between ten and fifteen million, although the officially reported tally was still much lower. Somewhere between one point five and two million people were still dying of smallpox per year. This was better, obviously, but it was also clear that a voluntary vaccination program wasn't going to be enough to eradicate smallpox. So the World Health Assembly back to proposal for an intensified smallpox eradication program, which would start on January first, nineteen sixty seven. Its goal was to eradicate smallpox worldwide within ten years, with the last naturally occurring case being found in Isolated by December thirty feet, nineteen seventy six. The intensified program was given an initial budget of two point five million dollars, and this was our money than before. But those thirty one countries where smallpox was still in endemic also had neighbors that needed to be protected from introduced cases, so this only worked out to about fifty thousand dollars per country. Donald A. Henderson, who was Chief of the Centers for Disease Control Smallpox Eradication Program, was made Chief Medical Officer of the Intensified Eradication Program, and in his account, this ten year goal was pretty arbitrary. It had been inspired by John F. Kennedy's declaration that the U. S Could land a man on the Moon within ten years. He also described the World Health Organization as pessimistic about the chances of success. W h O Director General Dr Marcolina Kandao was from Brazil and thought smallpox eradication would be impossible just in the Amazon Basin, much less anywhere else. According to Henderson, the World Health Organization wanted an American to head the program so that if it failed, the US would shoulder some of the blame rather than all of it falling on the w h O. I read a right up that Henderson wrote briefly about this uh, this campaign, and he had sort of spelled out how it sort of seemed like things were happening almost on a whim, and he was like, I'm just I'm writing this too. Disabuse you of the notion that there may have been extensive planning involved in the outset of this. We will get to how this intensified program, even though it still seemed a little haphazard, how it successfully eradicated smallpox after another quick sponsor break. When the World Health Organization established the Intensified Smallpox Eradication Program, smallpox was still endemic and multiple countries in Asia, South America, and Sub Saharan Africa, and especially at first, a lot the financial support and a lot of the vaccines for the program were coming from wealthier nations where smallpox had already been eradicated, nations like the United States, and for these countries, their motive was not just humanitarian. There was also a lot of money and politics involved. For example, if smallpox was eradicated worldwide, these nations would not need to fund vaccination programs in other countries or spend money vaccinating their own populations anymore. For wealthier countries, these smallpox vaccination programs also served as opportunities to vaccinate people for other diseases and to try to build political influence and goodwill in the places where the programs were operating. Also, countries where smallpox had been eradicated, still occasionally faced outbreaks that were usually introduced through travel. Although these tended to be very small and quickly contained, they were still disruptive and expensive and sometimes sparked a public panic. Global smallpox eradication would mean not having to deal with any of that anymore. Yeah, there was a lot of self interest involved in the wealthier nations who gave money and vaccine and other support to this whole program. Although each nation still needed a plan that was customized to its own needs. There also needed to be a better unifying strategy behind this whole program, something beyond a target of vaccinating of the population. That number I feel like keeps getting repeated today is like the standard for what is needed, but it had not really been based on epidemiology or on public health data. Had just seemed like a reasonable operational goal for the voluntary program, And it had also become clear that the number of vaccines administered did not really work as the goal, since teams might wind up vaccinating the same people more than once, driving up their vaccination numbers without actually vaccinating more of the population. One big gap that needed to be filled with this was surveillance reporting methods were still all over the place, and eradication was only possible if health officials actually knew when and where outbreaks were happening. This was something that just required a ton of communication from the World Health Organization and all through every level of a nation's governments, all the way down to individual doctors, hospitals, and community leaders who needed to report any suspected cases in order for this to work. Another gap was standards for the vaccine itself. The Soviet Union and the United States were the two biggest donors of vaccines, with the USSR donating a hundred and forty million doses a year and the United States donating forty million doses. Other countries donated as well, but in smaller amounts. In nineteen sixty seven, the World Health Organization asked vaccine manufacturers to submit samples of their smallpox vaccine, and only thirty percent of them met WHO standards for quality and potency. Some of us submitted vaccine samples did not contain any vaccinia virus at all. Others were contaminated with bacteria. Led to the WHO establishing more stringent standards for the vaccines and then monitoring them to make sure the vaccines actually met those standards. As all of this was happening, Of course, wars and other unrest we're making vaccination programs difficult. In some places where smallpox was still circulating, The Nigerian Civil War began in ninety seven, which made things more dangerous for health workers and their patients, and it also led to a vaccine shortage. But this shortage also led to a shift in how smallpox vaccinations were prioritized. Since there wasn't enough vaccine available for the whole population, health officials show used on vaccinating family members and other close contacts of anyone who developed smallpox. This turned out to be an effective way to stop the spread of the disease, and Nigeria's last smallpox case was reported in May of nineteen seventy. The focus on monitoring and reporting cases that was so necessary for the program's success also made it easier to see trends and how and where smallpox outbreaks developed. Vaccinators started taking better advantage of seasonal variations. They would use all that surveillance work to trace people's contacts and to vaccinate more people at the start of the season when the smallpox case numbers were lower to contain those outbreaks. Before they spread. By nineteen seventy three, smallpox existed in only five countries Bangladesh, India, Nepal, Pakistan, and Ethiopia. Bangladesh had previously been free of the disease, but it had been reintroduced there as refugees fled the Indo Pakistani War, and by this point, about eight percent of the vaccines being used for this effort were being made in the countries where they were being administered, and at least of the vaccines that the World Health Organization tested met its standards. Having only five countries remaining was obviously a huge accomplishment, But at the same time, more than seven hundred million people lived in Bangladesh, India, Pakistan, and Nepal. They were all neighboring countries, and it had become really obvious that a mass vaccination program just wasn't going to be able to eradicate the disease in this region. These neighboring nations had been trying to vaccinate their whole populations for years. There were a hundred and twenty thousand health staff working on the program in India alone, So the strategy shifted to mirror what had actually worked in Nigeria in the late nineteen sixties, health officials quarantined anyone who contracted small talks and used extensive contact tracing to determine who else might have been exposed. They vaccinated their immediate families and the surrounding communities. This became known as the ring method, basically making a ring of vaccinated people around each active smallpox case so that the disease just could not spread. Monitoring and surveillance were critically important to this process, since health workers could only make a vaccinated ring around cases of smallpox that they knew about, so health workers traveled from place to place, educating local doctors, healers, leaders, and officials about smallpox, reporting and seeking out and isolating active smallpox cases, and then vaccinating anyone who may have come into contact with these patients. Using this method, Pakistan saw its last reported case of smallpox in October of nineteen seventy four, Nepal in April of nineteen seventy five, India in May of nineteen seventy five, and bangal H in October of nineteen seventy Unfortunately, although Ethiopia's last case of smallpox was reported in August of nineteen seventy six. By that point it had been reintroduced into neighboring Somalia, which was still experiencing active cases. In nineteen seventy seven, Donald Henderson resigned as the head of the intensified eradication program. He was replaced by Asao Arita, who had been Medical Officer of Infectious Disease Control in the Ministry of Health and Welfare in Japan before joining the World Health Organization. That same year, nineteen seventy seven, authorities started trying to contain an outbreak a very elam minor among nomadic people's in the desert region that spans parts of Ethiopia, Somalia, and Kenya. Smallpox was reintroduced into Kenya, but that introduction was quickly contained, and Kenya reported its last case in February of nineteen seventy seven. In July of nineteen seventy seven, Somalia and Ethiopia went to war over control of part of this region, and then that hampered efforts to control this ongoing outbreak in Somalia. Somalia actually reported three hundred cases of smallpox in v seven. The last one was the case of Ali Maomalin, who was a cook at Merca Hospital. On October twelfth seven, a driver carrying two smallpox patients to an isolation camp stopped at the hospital to ask for directions. Malen got into the car and rode with them for fifteen minutes or less. He did that so he could guide them to where the leader of the smallpox surveillance team lived. These two patients were siblings six and one and a half years old, and when authorities traced their contacts, Maleen was overlooked. Although Maleen worked in a hospital, he wasn't vaccinated against smallpox. In an interview later in his life, he said that he had been afraid of the vaccine. There are a couple of accounts that said that he had been back to NATed but his vaccine hadn't taken, and that disagrees with the interview that he gave later. He started feeling sick on October nineteen seventy seven, and at first doctors thought he had malaria. Then he developed a rash on October six, and he was initially diagnosed with chicken pox. He started to worry that he had smallpox on October, and on October somebody reported to health officials that he had a potential smallpox case. His diagnosis was confirmed through lab tests that day. The effort to prevent Maulein's smallpox case from sparking another outbreak really demonstrates what was involved in all of this. Contact tracing identified one hundred sixty one possible exposures, some of them as far as a hundred and twenty kilometers away. This included hospital staff, family, and friends, many of whom had visited him while he was ill. Authorities identified thirty three face to face contacts who had no evidence of prior small pox infection and had not been vaccinated within the past three years, and twelve of those had no prior evidence of a smallpox infection or vaccine at all. All those people were vaccinated, along with all known and possible contacts and their families. During an eighteen day surveillance period. Health workers made multiple in person visits to each person who had potentially been exposed. The number and frequency of those visits depended on the person's relative level of exposure and their risks. So if they had been around him a long time and we're not vaccinated, they got multiple different visits from from the health staff. But if they had been vaccinated and it was a shorter time they might get two check ins. In the end, though none of those hundred and sixty one contacts developed smallpox, but it did not stop with those hundred and sixty one contacts. Warning signs were posted at Merca Hospital, which was placed under twenty four hour guard. Vaccines were administered to everyone who worked at the hospital and all of the patients. Patients in the surgical ward were quarantined until November, and in the medical ward they were quarantined until November seventeen. The hospital also suspended all non emergency care, referred outpatient procedures to other facilities, and required daily temperature checks for patients and staff. There was also a mass vaccination campaign and the ward of the city where Malin lived and the hospital was This was a multi phase process, was vaccinators going house to house to vaccinate everyone and to look for any signs of smallpox cases, and then returning to vaccinate anybody who had arrived since the last pass or whose first vaccines showed no evidence of a vaccine scar. Once that ward of the city was done, health workers did the same for the rest of the city. Checkpoints were established at all the roads and footpaths leading into market, and anyone who was her going was advised to this possible outbreak. They vaccinated everybody who was passing through, and then on top of all of that, there was a massive public information campaign with a reward for reporting smallpox cases. In the end, Ali ma Omalin was the last person to contract naturally occurring smallpox. That was ten years nine months in twenty six days after the start of the intensified eradication campaign, so it just barely missed that ten year goal, even if it had been arbitrary. After recovering from smallpox, Maline later became part of the effort to eradicate polio, working as a vaccinator and organizing door to door campaigns. He would share his own story about how he had been afraid to be vaccinated for smallpox and then had ultimately become the last smallpox patient. Somalia was declared free of polio in two thousand seven, but it re emerged there. When that happened, Malin went back to his vaccinating work. He suddenly became ill not long afterward, and he died on July of what was diagnosed as malaria. But the last person to die of smallpox contracted it after Malin did. That was Janet Parker, a medical photographer who was infected on the job at England's Birmingham University Medical School in night. The microbiology lab was one floor below her dark room in the office that she used to make phone calls. It is not clear exactly how she came into contact with smallpox virus from the lab. At the time, the prevailing theory was that it was through a shared air event, but later studies suggested that that was actually unlikely. Parker had been vaccinated for smallpox, but as we mentioned earlier, the vaccines protection was expected to last for about ten years, and she had been vaccinated back in nineteen sixty six. The strain she was exposed to was also a particularly deadly one. Her mother, Hilda Whitcomb, contracted smallpox while caring for her, but she recovered, but Janet's father, Frederick died of an apparent heart attack while in quarantine. Helda missed both his and Janet's funerals because of her own illness. Health workers quarantined hundreds of people who had possibly been exposed, and at least five hundred people were vaccinated to keep this outbreak from spreading any further. This lab had been scheduled to close as the World Health Organization tried to reduce the number of facilities that had samples of the virus. Although the lab had previously been inspected and was allowed to continue operation, it didn't have a lot of basic safety measures in place to contain deadly pathogens, things like changing facilities, dedicated showers, and airlocks. It also had been the source of another smallpox case, also involving a medical photographer, back in nineteen sixty six. It really seems like when they inspected the lab and they were like, it doesn't have all these things that we recommend to control potential spread of pathogens, but like, only three people work here, so it's probably fine. This became a huge scandal later. The labs director, Dr Henry Benson, had been trying to finish as much of his work as possible before the lab was closed. He blamed himself for Parker's illness and took his own life a few days before her death, which was on September eleventh. As this was happening, health officials were still closely monitoring other countries to confirm that smallpox was no longer circulating. There. On October nineteen seventy nine, a ceremony was held in their Robi to announce that smallpox had been eradicated in the Horn of Africa. That was two years after Ali Mao Malin had first developed a smallpox rash. On December nine, vy nine, the Global Commission for the Certification of Smallpox Eradication declared smallpox eradicated, and on May eighth, venteen eighty, the World Health Organization confirmed the disease eradication. There's been some stuff floating around social media lately about how this was only possible because everyone did their part, either implying or just flat out saying that everybody accepted the vaccine during this process, but that is just not true. There was a lot of resistance and hesitancy, especially in campaigns to vaccinate children. A lot of parents just didn't want to do something that might hurt their child or make them sick. The process of administering the vaccine also evolved over the years, and some parents that had like pretty traumatic vaccine experiences that they didn't want repeated with their child. Anti vaccine activists such as Lily Loate, who worked for the National Anti Vaccination League and edited its journal distributed literature against vaccines in general and against the smallpox vaccine specifically well into this eradication effort. Aside from that, because earlier versions of the smallpox vaccine were grown in the skin of live animals, animal rights activists and anti vivisectionists objected to their use when methods progressed to using tissue. Cultures mistrust of science lad people to object to this method as well. In places like India, smallpox vaccination had been a routine part of the public health service since nineteen seven, and yet there were still outbreaks for decades after that. This led people to claim that the vaccine was worthless, or even that it was what had been causing the smallpox. Nations stopped vaccinating people for smallpox once the disease had been eradicated from within their borders, and and some people this just reinforced that perception, like there were no vaccines happening anymore. That must be why there's no small box happening anymore. There were also religious objections to smallpox vaccinations. Various peoples and cultures interpreted smallpox as kind from divine will, or interpreted existing methods of smallpox prevention or treatment as religiously significant, and most of the last nations to eradicate smallpox were the same ones that had a long history of being colonized and exploited by European powers, so people were understandably suspicious of this largely Western led public health effort. So the global eradication of smallpox happened in spite of hesitancy and resistance, not in the absence of it, so that that's how smallpox was finally eradicated. It does still exist in a couple of labs. There have been ongoing conversations about destroying those remaining stocks, and that it keeps getting postponed. I would really like it if we as a global society could get control of the COVID nineteen pandemic, because unless the Carter Center program successfully and eradicates guinea worm disease and the immediate few, sure, we don't have any more eradications of diseases to cover on the show when I need an optimistic story related to all this, right, We're uh, that would be great to report as a history in the making, But fingers crossed, do you have some listener mail for us? I do have listener mail This is from Alex and Alex wrote after our Deportation of the Acadians episode and Alex route Hi, Tracy and Hallie. How surprised I was when I opened my podcast player yesterday and found finally an episode on the Acadian deportation. I immediately broke my rule of listening episodes in order because I was a few episodes behind. I'm a longtime listener and have suggested myself an episode on the subject a few years back. I do not know if it was on purpose or a lucky coincidence, but the release of the episode coincides with National Acadian Day, which is August fifteen. On this day, Acadians from munities and the maritime provinces in Quebec celebrate Acadian culture. This event is usually marked by a tentamar where people walk in the street at around six pm and start making noise by banging on pots and hands in a way to remind the rest of the world of our ongoing presence and resilience. Today, New Brunswick is about forty Francophone, mostly of Acadian heritage. New Brunswick is still the only officially bilingual province in Canada. Both English and French speaking communities coexist harmoniously, although some friction occasionally flares up, with some in the political arena blaming the bilingual status of the provinces a reason to explain the economic problems of the province. Outside the Maritimes, Quebec is probably the region with the most Acadian descent, with as researchers proved over the year, over a million of the seven million inhabitants are of Acadian descent. And the United States, many Acadians would assimilate into American culture, with most of them anglicizing their name. For example, some little blancs became white and so on. Alex ends with a personal note about family genealogy and uh in Acadian descent. So thank you so much, Alex. A couple of people wrote in about two things, One about New Brunswick being the only officially bilingual Canadian province, and a couple of people wrote in about August fifteen being National Acadian Day. Uh. That was a hundred percent coincidental, not even coincidental. It's like there, it was accidental. This episode was originally going to come out a little bit later, but we had a very very last minute schedule Switchery is the only reason the Acadian episode actually came out before August fifties instead of afterwards. So happy coincidences happened in our calendar sometimes, and that was one of them. So thanks so much Alex for sending this email. If you would like to email us about this or any other podcast, where a history podcast at i heart radio dot com. We're all over social media at miss in History. That's where you'll find our Facebook, Twitter, Pinterest, and Instagram. And you can subscribe to our show on the I heart radio app and anywhere else you like to get your podcasts. Stuff you Missed in History Class is a production of I heart Radio. For more podcasts from I heart Radio, visit the iHeart Radio app, Apple Podcasts, or wherever you listen to your favorite shows.

Welcome to Stuff You Missed in History Class, a production of I Heart Radio. Hello, and welcome to the podcast. I'm Tracy V. Wilson and I'm Holly Fry. Late March of last year, I researched and wrote our episode on the eradication of render pest because in that moment, it just felt really weird to me to work on episodes that were not about the pandemic somehow, because that was dominating everything in our lives. But at the same time, I wanted to work on something that felt kind of optimistic because the pandemic was dominating our lives. Uh So, now it's almost a year and a half later here in the US, we had a pretty hopeful springtime regarding the progress of the pandemic. I know that was not the case in the whole world, but we had what was looking like improved situations that obviously has taken a turn once again for the worst, or at least the worst, maybe not the worst of ever, but definitely worse. I wanted to kind of return to the idea of wiping a disease off the face of the earth. So render pest and smallpox are the only two diseases that have been eradicated through human activity. Neither one of them is technically extinct, because there are some samples of both viruses that still exist in labs. They're no longer circulating out in the wild, though. And we've talked about smallpox a bit on the show before. We had our episode on Edward Jenner and the smallpox vaccine and how the vaccine was developed and then generous efforts to try to make it more widely available. More recently, we did the episode on the Royal Philanthropic Vaccine Expedition, and that was all about Spain's efforts to transport the smallpox vaccine to the America's which required a chain of living hum and hosts. We mentioned pretty briefly the eradication of smallpox and both of those episodes, but we have not gone into detail about how that happened. That's what we're going to talk about today. And when Tracy mentioned it to me, I said, we've covered that. No, it just keeps coming up. It just keeps coming up. We've said in like a sentence how it was done, but it's a more than a sentence worth of explanation. Yeah, it's just it's a it's been just peppered in enough that my brain was like, yeah, that that was an episode, right, No, Nope. So smallpox is a viral disease that has existed for millennia when it was circulating in the wild. It's spread from person to person through the air, usually through face to face contact, and it can also be spread through contact with contaminated objects and surfaces. People who contracted smallpox typically developed a high fever and body aches, and that was followed by a distinctive rash. There are two different strains of the very Ola virus that were causing smallpox, very il a major and verial a minor. As that name suggests, very el a major caused more serious illnesses. As many as a third of people who were infected with very Ola major died, as many as nine of babies died. It was also particularly lethal any time it was introduced somewhere that it hadn't existed before, such as when Europeans started arriving in the Americas, and in those cases, smallpox usually killed about half the people who contracted it Among the people who survived the disease. Smallpox could also be both disabling and disfiguring. There was and is no cure for smallpox, so even as science and medicine progressed, it continued to be deadly. But it also had some traits that made it a good candidate for a worldwide eradication campaign. Smallpox was easy to recognize and diagnose. Unlike say, the flu, which can resemble a lot of other respiratory infections, smallpox passed directly from person to person and only infected humans, so there were no hidden reservoirs of the virus that could potentially start a new outbreak. That's different from something like yellow fever, which also infects other primates and is transmitted by mosquitoes. Another plus, once a person had recovered from smallpox, they were immune for life. For a number of reasons, smallpox outbreaks also tended to develop relatively slowly. Once people were contagious, they were usually also too sick to really leave home, so outbreaks tended to cluster around members of the same household and their immediate neighborhood. And then once an outbreak was identified, swift action could keep it from spreading very far. And most importantly, there was a way to disrupt transmission of the disease in this case of vaccine in terms of the smallpox vaccine. At first, people prevented smallpox using a technique called variolation that involved intentionally introducing material from one person's smallpox sore or scab into another person. Practitioners in Asia were doing this as early as the eleventh century, and the technique spread from there. Then, in the late eighteenth century, people started to make a connection between smallpox and another much milder disease that was called cow pox. The smallpox and cow pox viruses are both in the genus orthopox virus, and people who had contracted cow pox seemed immune to smallpox. Several people, including Edward Jenner, tried deliberately exposing people to cow pox as a way to prevent smallpox. Jenner called this vaccination, after the Latin word for cow. So both variolation and vaccination could prevent smallpox, but since variolation could also cause full blown smallpox, vaccination was a lot safer. At the same time, though, vaccination in its earliest forms carried some of the same risks that variolation did, including the potential for transmitting other illnesses like syphilis and hepatitis from person to person. During these person to person vaccination chains. Sometime in the nineteenth century, people shifted from using cow pox to using vaccinia virus, which is another orthopox virus, to make smallpox vaccine. The origins of the vaccinia virus are unclear. It is possible that it's actually some kind of hybrid of cow pox and smallpox, or that it developed over time as cow pox virus was passed through multiple hosts in the process of making vaccines. Eventually, vaccinia virus replaced cow pox virus for vaccination purposes, just as vaccination with cowpox had previously replaced variolation with smallpox itself. At first, vaccines made with vaccinia virus were grown in the skin of live animals like calves, sheep, and rabbits. Eventually that shifted to growing the virus in tissue cultures or in chicken eggs. These methods replaced those arm to arm vaccination chains that we talked about in our episode on the Royal Philanthropic Vaccine Expedition. Countries actually started to outlaw arm to arm vaccinations in the late nineteenth century. Many of the vaccinia strains used to make vaccines were attenuated or weakened by repeatedly passing them through a non human host, things like chick embryo cells, eggs, or mice. This process resulted in a virus that produced an immune response when a person was vaccinated with it, but couldn't reproduce in that person's body and make them sick. So while vaccination with cowpox virus was safer than variolation with smallpox virus, vaccination with an attenuated version of vaccinia virus was also safer than vaccination with live, unattenuated cow pox. Yeah, there were still potentials for various complications, but this was an improvement overall. It really didn't take long after the development of vaccines for people to wonder whether vaccines could be used to eliminate smallpox entirely, but early attempts to do this faced a lot of obstacles. As we talked about in our episode on the Royal Philanthropic Vaccine Expedition, Early versions of smallpox vaccine lost their potency really quickly, especially in hot weather, and that continued to be true after vaccinia replaced cow pox as the preferred virus for smallpox vaccines. But then in the nineteen forties people started working on dehydrated and freeze dried versions of the vaccine. The Vaccine Institute in Paris produced a freeze dride vacuum packed vaccine that had a longer shelf life. In the nineteen fifties, Leslie Harold Collier at the Lister Institute study the preservation methods that were in use and how effective they were. In he developed a process that didn't require refrigeration, even in tropical temperatures. Once the vaccine was reconstituted, it still had a short shelf life, but until that point it could survive in the field for months. It also protected people from smallpox infection for at least ten years, and offered protection against dying of smallpox for some time after that. Callier's method eventually became the World Health Organization standard for vaccine used for the eradication campaign. Smallpox was eliminated in North America in nineteen fifty two and in Europe in nineteen fifty three, and that was done primarily through mass vaccination campaigns, especially once that were done in response to outbreaks. And this success came in spite of increasing resistance to vaccines and to compulsory vaccine programs and the United States. This resistance led to a Supreme Court case in nineteen o five, the city of Cambridge, Massachusetts, had been trying to stop a small pox outbreak and had ordered all adults to be vaccinated or to pay a five dollar fine. Henning Jakobsen refused to be vaccinated, and then, after being fined, he took the matter to court. In the words of the court's decision, quote, the liberty secured by the Constitution of the United States does not import an absolute right in each person to be at all times and in all circumstances, wholly freed from restraint. Nor is it an element in such liberty that one person or a minority of persons residing in any community and enjoying the benefits of local government, should have power to dominate the majority, when supported in their action by the authority of the state. It is within the police power of a state to enact a compulsory vaccination law, and it is for the legislature and not for the courts, to determine in the first instance, whether vaccination is or is not the best mode for the prevention of smallpox and the protection of the public health. We'll get some more on the campaign to eradicate smallpox and the rest of the world after a sponsor break. The World Health Organization's decision making body is called the World Health Assembly, and in nineteen fifty three, the w h A didn't consider smallpox to be a candidate for global eradication. It just wasn't a priority. But five years later a delegate to the w h A proposed a ten year eradication plan. That delegate was Professor Viktor Jdanoff, who was Deputy Health Minister of the Soviet Union, and this proposal included vaccine donations that would be provided by the USSR. But even with the promise of donated vaccines, this proposal still didn't pass. At the time, the World Health Organization was working on an anti malaria program and that was really just drawing most of the focus. In nineteen fifty nine, the Soviet Union's proposal was reintroduced, and this time it was passed as a voluntary global vaccine campaign. Countries where smallpox was endemic, that is, freely circulating, were asked to institute mass vaccine programs with a goal of vaccinating eight of their populations, and the countries where it wasn't, which were generally richer, were asked to contribute funding or vaccines towards the effort. At that point, smallpox was being reported in sixty three countries, and together those countries reported seventy seven thousand, five hundred fifty five cases of the disease. But it became obvious really fast that that number was way, way too low. For one thing, those sixty three countries only included the ones that were members of the World Health Organization, and some countries where smallpox was endemic were not members at that point, and that included China, which had a population of more than six hundred and sixty million people. But even in those sixty three countries, reporting was all over the place. In countries without a lot of public health infrastructure, smallpox cases weren't really being tracked. But even in places where that wasn't the case, sometimes the only smallpox infections being reported were the ones that ended up in hospitals. In reality, the countries or smallpox was still endemic in ninety nine were home to more than half the world's population, and that total number of annual cases was probably more like fifty million, not seventy seven thousand. This voluntary program was focused on national vaccine campaigns, and at least in theory, each nation's campaign would be tailored for its own culture, needs, resources, and infrastructure, but that also meant there was really no central strategy at work. The World Health Organization's role was mostly just making sure that there was enough vaccine available and providing assistance if nations asked for it. It wasn't really coordinating efforts. Are doing a lot of tracking and monitoring, and because under reporting of cases continued to be a huge problem, it was almost impossible to tell whether these national programs were even working. That made it much harder to secure funding or to rally support from nations that had already eradicated smallpox within their own borders, and for the most part, these early national campaigns were not working at least not very well. In many places, success was measured by how many vaccines were administered. Sometimes this led vaccinators to go after the easiest targets first, like vaccinating all the students at a school, but that meant that children in more outlying areas who were not attending school were not being vaccinated. Since there often weren't clear records, it wasn't unheard of for vaccinators to go back to the same school and vaccinate children again. Even though a successful smallpox vaccine typically left a recognizable scar be because of issues like this. At one point, India was reporting a vaccination rate of a hundred and forty because so many people were being vaccinated more than once. Things moved pretty slowly with all this for about five years, but then in nineteen sixty four, Dr Korrel Rashka of Czechoslovakia, who was a huge advocate of smallpox eradication, became Director of the Division of Communicable Diseases at the World Health Organization. In nineteen sixty five, the World Health Organization established a dedicated smallpox eradication unit, and that same year President Lyndon Johnson announced that the United States would start supporting the global smallpox eradication program. Soon, the US was supporting the work of the Pan American Health Organization in South America and also funding major vaccine efforts in Western and Central Africa. These years also saw improvements in how smallpox vaccines were administered. Most vaccines that people receive today are administered as shots. They go into the muscle or the subcutaneous skin layer using a needle, but smallpox vaccine goes into the skins superficial layers by the mid nineteen sixties. There were a few different methods for doing this. One was to scratch a person's skin with a needle or lancet, and another was to repeatedly press the tip of the needle into a person's skin. Neither of these methods was very precise. Depending on how skilled the vaccinator was, they might press the needle too far into the skin or not far enough. The amount of vaccine on the needle usually depended on things like how deeply it had been inserted into the vaccine bile. Excess vaccine was often left behind on a person's skin and left to either dry there or be wiped away. Kind of wasteful. It's so fascinating to me to think about this when I think most of the vaccines I've received are like those pre measured very carefully, like you open the uh dose and that's it. Yeah. So the margin for error of it is a little bit mind boggling. Yeah. And there are for sure vaccines that are not administered with shots at this point, but the shots, at least here in the US, are the majority of them. The standard Yeah, jet injector devices were made to try to address some of this and to make vaccinating more efficient. In theory, these could vaccinate one thousand people an hour, but in practice they were limited. Some required electricity to work, and others were operated with a foot pedal that was clunky, so these were only really practical in places where you could bring huge groups of people to one location to be vaccinated. Plus, these devices were expensive, and they were hard to clean, and they were prone to breaking down. But then Dr Benjamin A. Ruben developed the bifurcated needle, which was patented in July of nine. This was a simple needle and when it was started into a vaccine vial, it picked up one measured dose of liquid in between the two prongs. The prongs themselves were designed to keep the needle at the correct angle and depth with a person's skin, and the two pronged structure meant that it needed fewer presses into the skin to administer each vaccine. This made everything way more efficient. One vial of vaccine could be used to vaccinate four times as many people, and people could be trained to administer the vaccine with the bifurcated needle in about fifteen minutes, even if they had no previous medical experience. Plus, the bifurcated needles were cheap to produce, although they were originally intended to be disposable at the World Health Organization's request, they were made from a steel alloy, they could hold up to boiling or flaming. They could be sterilized and reused over and over before they started to dull. Boilable containers were designed so that vaccinators could drop used needles into the container as they went and boiled the whole thing at the end of a shift. Also, it was standard practice to clean a person's arm with paths that were soaked in alcohol or soap before giving them the vaccine. I know every time I've gotten a shot, there's been a little alcohol wiped down on the injection site. But studies had suggested that this wasn't actually removing bacteria or other contaminants, it was just sort of moving things around. Studies confirmed that the number of complications and secondary infections after smallpox vaccination was the same regardless of whether the vaccine site was wiped down beforehand or not, so most vaccination programs, especially in like more impoverished areas, dropped this step, and together all of this brought the cost for smallpox vaccination down to about ten cents a person. By nineteen sixty six, smallpox was endemic in thirty one country piece. That was down from the sixty three or more reported back in nineteen fifty nine. The number of estimated worldwide cases had dropped from about fifty million to somewhere between ten and fifteen million, although the officially reported tally was still much lower. Somewhere between one point five and two million people were still dying of smallpox per year. This was better, obviously, but it was also clear that a voluntary vaccination program wasn't going to be enough to eradicate smallpox. So the World Health Assembly back to proposal for an intensified smallpox eradication program, which would start on January first, nineteen sixty seven. Its goal was to eradicate smallpox worldwide within ten years, with the last naturally occurring case being found in Isolated by December thirty feet, nineteen seventy six. The intensified program was given an initial budget of two point five million dollars, and this was our money than before. But those thirty one countries where smallpox was still in endemic also had neighbors that needed to be protected from introduced cases, so this only worked out to about fifty thousand dollars per country. Donald A. Henderson, who was Chief of the Centers for Disease Control Smallpox Eradication Program, was made Chief Medical Officer of the Intensified Eradication Program, and in his account, this ten year goal was pretty arbitrary. It had been inspired by John F. Kennedy's declaration that the U. S Could land a man on the Moon within ten years. He also described the World Health Organization as pessimistic about the chances of success. W h O Director General Dr Marcolina Kandao was from Brazil and thought smallpox eradication would be impossible just in the Amazon Basin, much less anywhere else. According to Henderson, the World Health Organization wanted an American to head the program so that if it failed, the US would shoulder some of the blame rather than all of it falling on the w h O. I read a right up that Henderson wrote briefly about this uh, this campaign, and he had sort of spelled out how it sort of seemed like things were happening almost on a whim, and he was like, I'm just I'm writing this too. Disabuse you of the notion that there may have been extensive planning involved in the outset of this. We will get to how this intensified program, even though it still seemed a little haphazard, how it successfully eradicated smallpox after another quick sponsor break. When the World Health Organization established the Intensified Smallpox Eradication Program, smallpox was still endemic and multiple countries in Asia, South America, and Sub Saharan Africa, and especially at first, a lot the financial support and a lot of the vaccines for the program were coming from wealthier nations where smallpox had already been eradicated, nations like the United States, and for these countries, their motive was not just humanitarian. There was also a lot of money and politics involved. For example, if smallpox was eradicated worldwide, these nations would not need to fund vaccination programs in other countries or spend money vaccinating their own populations anymore. For wealthier countries, these smallpox vaccination programs also served as opportunities to vaccinate people for other diseases and to try to build political influence and goodwill in the places where the programs were operating. Also, countries where smallpox had been eradicated, still occasionally faced outbreaks that were usually introduced through travel. Although these tended to be very small and quickly contained, they were still disruptive and expensive and sometimes sparked a public panic. Global smallpox eradication would mean not having to deal with any of that anymore. Yeah, there was a lot of self interest involved in the wealthier nations who gave money and vaccine and other support to this whole program. Although each nation still needed a plan that was customized to its own needs. There also needed to be a better unifying strategy behind this whole program, something beyond a target of vaccinating of the population. That number I feel like keeps getting repeated today is like the standard for what is needed, but it had not really been based on epidemiology or on public health data. Had just seemed like a reasonable operational goal for the voluntary program, And it had also become clear that the number of vaccines administered did not really work as the goal, since teams might wind up vaccinating the same people more than once, driving up their vaccination numbers without actually vaccinating more of the population. One big gap that needed to be filled with this was surveillance reporting methods were still all over the place, and eradication was only possible if health officials actually knew when and where outbreaks were happening. This was something that just required a ton of communication from the World Health Organization and all through every level of a nation's governments, all the way down to individual doctors, hospitals, and community leaders who needed to report any suspected cases in order for this to work. Another gap was standards for the vaccine itself. The Soviet Union and the United States were the two biggest donors of vaccines, with the USSR donating a hundred and forty million doses a year and the United States donating forty million doses. Other countries donated as well, but in smaller amounts. In nineteen sixty seven, the World Health Organization asked vaccine manufacturers to submit samples of their smallpox vaccine, and only thirty percent of them met WHO standards for quality and potency. Some of us submitted vaccine samples did not contain any vaccinia virus at all. Others were contaminated with bacteria. Led to the WHO establishing more stringent standards for the vaccines and then monitoring them to make sure the vaccines actually met those standards. As all of this was happening, Of course, wars and other unrest we're making vaccination programs difficult. In some places where smallpox was still circulating, The Nigerian Civil War began in ninety seven, which made things more dangerous for health workers and their patients, and it also led to a vaccine shortage. But this shortage also led to a shift in how smallpox vaccinations were prioritized. Since there wasn't enough vaccine available for the whole population, health officials show used on vaccinating family members and other close contacts of anyone who developed smallpox. This turned out to be an effective way to stop the spread of the disease, and Nigeria's last smallpox case was reported in May of nineteen seventy. The focus on monitoring and reporting cases that was so necessary for the program's success also made it easier to see trends and how and where smallpox outbreaks developed. Vaccinators started taking better advantage of seasonal variations. They would use all that surveillance work to trace people's contacts and to vaccinate more people at the start of the season when the smallpox case numbers were lower to contain those outbreaks. Before they spread. By nineteen seventy three, smallpox existed in only five countries Bangladesh, India, Nepal, Pakistan, and Ethiopia. Bangladesh had previously been free of the disease, but it had been reintroduced there as refugees fled the Indo Pakistani War, and by this point, about eight percent of the vaccines being used for this effort were being made in the countries where they were being administered, and at least of the vaccines that the World Health Organization tested met its standards. Having only five countries remaining was obviously a huge accomplishment, But at the same time, more than seven hundred million people lived in Bangladesh, India, Pakistan, and Nepal. They were all neighboring countries, and it had become really obvious that a mass vaccination program just wasn't going to be able to eradicate the disease in this region. These neighboring nations had been trying to vaccinate their whole populations for years. There were a hundred and twenty thousand health staff working on the program in India alone, So the strategy shifted to mirror what had actually worked in Nigeria in the late nineteen sixties, health officials quarantined anyone who contracted small talks and used extensive contact tracing to determine who else might have been exposed. They vaccinated their immediate families and the surrounding communities. This became known as the ring method, basically making a ring of vaccinated people around each active smallpox case so that the disease just could not spread. Monitoring and surveillance were critically important to this process, since health workers could only make a vaccinated ring around cases of smallpox that they knew about, so health workers traveled from place to place, educating local doctors, healers, leaders, and officials about smallpox, reporting and seeking out and isolating active smallpox cases, and then vaccinating anyone who may have come into contact with these patients. Using this method, Pakistan saw its last reported case of smallpox in October of nineteen seventy four, Nepal in April of nineteen seventy five, India in May of nineteen seventy five, and bangal H in October of nineteen seventy Unfortunately, although Ethiopia's last case of smallpox was reported in August of nineteen seventy six. By that point it had been reintroduced into neighboring Somalia, which was still experiencing active cases. In nineteen seventy seven, Donald Henderson resigned as the head of the intensified eradication program. He was replaced by Asao Arita, who had been Medical Officer of Infectious Disease Control in the Ministry of Health and Welfare in Japan before joining the World Health Organization. That same year, nineteen seventy seven, authorities started trying to contain an outbreak a very elam minor among nomadic people's in the desert region that spans parts of Ethiopia, Somalia, and Kenya. Smallpox was reintroduced into Kenya, but that introduction was quickly contained, and Kenya reported its last case in February of nineteen seventy seven. In July of nineteen seventy seven, Somalia and Ethiopia went to war over control of part of this region, and then that hampered efforts to control this ongoing outbreak in Somalia. Somalia actually reported three hundred cases of smallpox in v seven. The last one was the case of Ali Maomalin, who was a cook at Merca Hospital. On October twelfth seven, a driver carrying two smallpox patients to an isolation camp stopped at the hospital to ask for directions. Malen got into the car and rode with them for fifteen minutes or less. He did that so he could guide them to where the leader of the smallpox surveillance team lived. These two patients were siblings six and one and a half years old, and when authorities traced their contacts, Maleen was overlooked. Although Maleen worked in a hospital, he wasn't vaccinated against smallpox. In an interview later in his life, he said that he had been afraid of the vaccine. There are a couple of accounts that said that he had been back to NATed but his vaccine hadn't taken, and that disagrees with the interview that he gave later. He started feeling sick on October nineteen seventy seven, and at first doctors thought he had malaria. Then he developed a rash on October six, and he was initially diagnosed with chicken pox. He started to worry that he had smallpox on October, and on October somebody reported to health officials that he had a potential smallpox case. His diagnosis was confirmed through lab tests that day. The effort to prevent Maulein's smallpox case from sparking another outbreak really demonstrates what was involved in all of this. Contact tracing identified one hundred sixty one possible exposures, some of them as far as a hundred and twenty kilometers away. This included hospital staff, family, and friends, many of whom had visited him while he was ill. Authorities identified thirty three face to face contacts who had no evidence of prior small pox infection and had not been vaccinated within the past three years, and twelve of those had no prior evidence of a smallpox infection or vaccine at all. All those people were vaccinated, along with all known and possible contacts and their families. During an eighteen day surveillance period. Health workers made multiple in person visits to each person who had potentially been exposed. The number and frequency of those visits depended on the person's relative level of exposure and their risks. So if they had been around him a long time and we're not vaccinated, they got multiple different visits from from the health staff. But if they had been vaccinated and it was a shorter time they might get two check ins. In the end, though none of those hundred and sixty one contacts developed smallpox, but it did not stop with those hundred and sixty one contacts. Warning signs were posted at Merca Hospital, which was placed under twenty four hour guard. Vaccines were administered to everyone who worked at the hospital and all of the patients. Patients in the surgical ward were quarantined until November, and in the medical ward they were quarantined until November seventeen. The hospital also suspended all non emergency care, referred outpatient procedures to other facilities, and required daily temperature checks for patients and staff. There was also a mass vaccination campaign and the ward of the city where Malin lived and the hospital was This was a multi phase process, was vaccinators going house to house to vaccinate everyone and to look for any signs of smallpox cases, and then returning to vaccinate anybody who had arrived since the last pass or whose first vaccines showed no evidence of a vaccine scar. Once that ward of the city was done, health workers did the same for the rest of the city. Checkpoints were established at all the roads and footpaths leading into market, and anyone who was her going was advised to this possible outbreak. They vaccinated everybody who was passing through, and then on top of all of that, there was a massive public information campaign with a reward for reporting smallpox cases. In the end, Ali ma Omalin was the last person to contract naturally occurring smallpox. That was ten years nine months in twenty six days after the start of the intensified eradication campaign, so it just barely missed that ten year goal, even if it had been arbitrary. After recovering from smallpox, Maline later became part of the effort to eradicate polio, working as a vaccinator and organizing door to door campaigns. He would share his own story about how he had been afraid to be vaccinated for smallpox and then had ultimately become the last smallpox patient. Somalia was declared free of polio in two thousand seven, but it re emerged there. When that happened, Malin went back to his vaccinating work. He suddenly became ill not long afterward, and he died on July of what was diagnosed as malaria. But the last person to die of smallpox contracted it after Malin did. That was Janet Parker, a medical photographer who was infected on the job at England's Birmingham University Medical School in night. The microbiology lab was one floor below her dark room in the office that she used to make phone calls. It is not clear exactly how she came into contact with smallpox virus from the lab. At the time, the prevailing theory was that it was through a shared air event, but later studies suggested that that was actually unlikely. Parker had been vaccinated for smallpox, but as we mentioned earlier, the vaccines protection was expected to last for about ten years, and she had been vaccinated back in nineteen sixty six. The strain she was exposed to was also a particularly deadly one. Her mother, Hilda Whitcomb, contracted smallpox while caring for her, but she recovered, but Janet's father, Frederick died of an apparent heart attack while in quarantine. Helda missed both his and Janet's funerals because of her own illness. Health workers quarantined hundreds of people who had possibly been exposed, and at least five hundred people were vaccinated to keep this outbreak from spreading any further. This lab had been scheduled to close as the World Health Organization tried to reduce the number of facilities that had samples of the virus. Although the lab had previously been inspected and was allowed to continue operation, it didn't have a lot of basic safety measures in place to contain deadly pathogens, things like changing facilities, dedicated showers, and airlocks. It also had been the source of another smallpox case, also involving a medical photographer, back in nineteen sixty six. It really seems like when they inspected the lab and they were like, it doesn't have all these things that we recommend to control potential spread of pathogens, but like, only three people work here, so it's probably fine. This became a huge scandal later. The labs director, Dr Henry Benson, had been trying to finish as much of his work as possible before the lab was closed. He blamed himself for Parker's illness and took his own life a few days before her death, which was on September eleventh. As this was happening, health officials were still closely monitoring other countries to confirm that smallpox was no longer circulating. There. On October nineteen seventy nine, a ceremony was held in their Robi to announce that smallpox had been eradicated in the Horn of Africa. That was two years after Ali Mao Malin had first developed a smallpox rash. On December nine, vy nine, the Global Commission for the Certification of Smallpox Eradication declared smallpox eradicated, and on May eighth, venteen eighty, the World Health Organization confirmed the disease eradication. There's been some stuff floating around social media lately about how this was only possible because everyone did their part, either implying or just flat out saying that everybody accepted the vaccine during this process, but that is just not true. There was a lot of resistance and hesitancy, especially in campaigns to vaccinate children. A lot of parents just didn't want to do something that might hurt their child or make them sick. The process of administering the vaccine also evolved over the years, and some parents that had like pretty traumatic vaccine experiences that they didn't want repeated with their child. Anti vaccine activists such as Lily Loate, who worked for the National Anti Vaccination League and edited its journal distributed literature against vaccines in general and against the smallpox vaccine specifically well into this eradication effort. Aside from that, because earlier versions of the smallpox vaccine were grown in the skin of live animals, animal rights activists and anti vivisectionists objected to their use when methods progressed to using tissue. Cultures mistrust of science lad people to object to this method as well. In places like India, smallpox vaccination had been a routine part of the public health service since nineteen seven, and yet there were still outbreaks for decades after that. This led people to claim that the vaccine was worthless, or even that it was what had been causing the smallpox. Nations stopped vaccinating people for smallpox once the disease had been eradicated from within their borders, and and some people this just reinforced that perception, like there were no vaccines happening anymore. That must be why there's no small box happening anymore. There were also religious objections to smallpox vaccinations. Various peoples and cultures interpreted smallpox as kind from divine will, or interpreted existing methods of smallpox prevention or treatment as religiously significant, and most of the last nations to eradicate smallpox were the same ones that had a long history of being colonized and exploited by European powers, so people were understandably suspicious of this largely Western led public health effort. So the global eradication of smallpox happened in spite of hesitancy and resistance, not in the absence of it, so that that's how smallpox was finally eradicated. It does still exist in a couple of labs. There have been ongoing conversations about destroying those remaining stocks, and that it keeps getting postponed. I would really like it if we as a global society could get control of the COVID nineteen pandemic, because unless the Carter Center program successfully and eradicates guinea worm disease and the immediate few, sure, we don't have any more eradications of diseases to cover on the show when I need an optimistic story related to all this, right, We're uh, that would be great to report as a history in the making, But fingers crossed, do you have some listener mail for us? I do have listener mail This is from Alex and Alex wrote after our Deportation of the Acadians episode and Alex route Hi, Tracy and Hallie. How surprised I was when I opened my podcast player yesterday and found finally an episode on the Acadian deportation. I immediately broke my rule of listening episodes in order because I was a few episodes behind. I'm a longtime listener and have suggested myself an episode on the subject a few years back. I do not know if it was on purpose or a lucky coincidence, but the release of the episode coincides with National Acadian Day, which is August fifteen. On this day, Acadians from munities and the maritime provinces in Quebec celebrate Acadian culture. This event is usually marked by a tentamar where people walk in the street at around six pm and start making noise by banging on pots and hands in a way to remind the rest of the world of our ongoing presence and resilience. Today, New Brunswick is about forty Francophone, mostly of Acadian heritage. New Brunswick is still the only officially bilingual province in Canada. Both English and French speaking communities coexist harmoniously, although some friction occasionally flares up, with some in the political arena blaming the bilingual status of the provinces a reason to explain the economic problems of the province. Outside the Maritimes, Quebec is probably the region with the most Acadian descent, with as researchers proved over the year, over a million of the seven million inhabitants are of Acadian descent. And the United States, many Acadians would assimilate into American culture, with most of them anglicizing their name. For example, some little blancs became white and so on. Alex ends with a personal note about family genealogy and uh in Acadian descent. So thank you so much, Alex. A couple of people wrote in about two things, One about New Brunswick being the only officially bilingual Canadian province, and a couple of people wrote in about August fifteen being National Acadian Day. Uh. That was a hundred percent coincidental, not even coincidental. It's like there, it was accidental. This episode was originally going to come out a little bit later, but we had a very very last minute schedule Switchery is the only reason the Acadian episode actually came out before August fifties instead of afterwards. So happy coincidences happened in our calendar sometimes, and that was one of them. So thanks so much Alex for sending this email. If you would like to email us about this or any other podcast, where a history podcast at i heart radio dot com. We're all over social media at miss in History. That's where you'll find our Facebook, Twitter, Pinterest, and Instagram. And you can subscribe to our show on the I heart radio app and anywhere else you like to get your podcasts. Stuff you Missed in History Class is a production of I heart Radio. For more podcasts from I heart Radio, visit the iHeart Radio app, Apple Podcasts, or wherever you listen to your favorite shows.