The difference between an epidemic and a pandemic rests on the extent to which a disease spreads. When an infectious disease appears in a location where it is not normally present and affects a large number of people, it is known as an epidemic. Epidemics can last weeks to years. They are temporary and will eventually disappear. Epidemics are also localized, appearing in villages, towns, or cities. When an infectious disease with these characteristics spreads throughout a country, continent, or larger area, it is known as a pandemic. History has documented numerous epidemics and pandemics, including recent outbreaks of H1N1 (swine flu) and severe acute respiratory syndrome (SARS), a serious form of pneumonia. For its long, varied, and at times dramatic history, smallpox, also known as variola, provides an excellent case study in epidemics and pandemics and the debates and issues that surround them.
I. Early Vaccines
II. Morally Reprehensible in America
III. Biological Weaponry
IV. Crossing Species
V. Religion and Disease
In 430 BC the population of Athens was hit hard by an unknown plague. The plague, documented by Thucydides, claimed approximately one third of the population. Some contemporary historians speculate that this unknown plague was actually smallpox. Similar plagues thought to be smallpox continued to appear throughout the Roman Empire from 165 to 180 BC and 251–266 BC. What we now know as smallpox entered western Europe in 581 AD, and eventually its presence became a routine aspect of life in the larger cities of Europe, such as London and Paris, where it killed 25 to 30 percent of those infected. By the 18th century, smallpox was certainly endemic and responsible for an average of 400,000 deaths per year in Europe and the disfigurement of countless additional individuals.
In 1718 Lady Mary Wortley Montagu brought the practice of variolation to England from Turkey. The procedure was quite simple: a needle was used to scratch a healthy individual’s skin, just breaking the surface; a single drop of the smallpox matter was added to the scratch and then loosely bandaged. If this was performed successfully, the individual would progress through an accelerated and mild case of smallpox, resulting in no scars and lifelong immunity.
The mortality rate for smallpox acquired in this manner was 1 to 2 percent, a considerable improvement over smallpox caught in the natural way, which had a mortality rate between 10 and 40 percent. When she returned to England, Lady Montagu variolated both of her children.
Most of London’s well-to-do society recoiled in horror at the act of purposely giving an individual the pox. As a result, Lady Montagu was ostracized by all except her closest friends. Her actions sparked hot debates in the chambers of the London Royal Medical Society over the ethics of deliberately exposing an individual to smallpox, of the efficacy of the procedure, and of the methods of the procedure itself. Given the known mortality rate of smallpox and the success of Lady Montague’s variolation on her children, however, it was not long before others began requesting that the procedure be performed on themselves and their children. After smallpox claimed the life of Queen Mary in 1692 and almost killed Princess Anne in 1721, members of the royal family became interested in the potential of variolation, influencing the opinions of the royal physicians.
Before members of the royal family could be subjected to the procedure, royal physicians demanded proof of the procedure’s success through human experimentation. Several inmates scheduled to be hanged at Newgate Prison, London, who had not had smallpox, as well as one individual who had already had the pox, were chosen and subjected to the procedure. It is not known whether these subjects were chosen or if they volunteered, although it seems doubtful that they would have had a choice in the matter. The manner in which the experiment was performed would certainly be condemned by modern scientists as well as ethicists. The subjects were kept together in a separate cell and monitored daily by physicians. A constant stream of visitors, both medical and civilian, came to observe the infected prisoners in their cell. After all the subjects had made full recoveries, the procedure was considered successful as well as morally acceptable. It is interesting to note that in England, variolation required a specially trained physician, whereas in Turkey, where the practice originated, the procedure was generally performed by an elderly woman in the village.
The case of smallpox raises a number of issues concerning diseases that reach epidemic and pandemic levels. The introduction of a non-Western medical procedure by a nonprofessional, Lady Montagu, created a considerable amount of contention among physicians of the time. Although its long local history in Turkey, as well as its use by Lady Montagu’s private physician, indicated that the procedure was successful, it was not until after the favorable outcome of an “official” experiment, executed under the auspices of the London Royal Medical Society and royal physicians, that the procedure was considered both safe and effective. Individuals who sought to practice variolation put themselves at risk of bodily harm from citizens driven by fear and panic. This was the case until local authorities determined that the practice was safe.
Morally Reprehensible in America
Around the same time, medical controversy spread to America, specifically to Boston. The Reverend Cotton Mather is generally credited with bringing variolation to North America, having “discovered” the practice after a discussion with his slave who responded, “yes . . . and no” when asked if he had suffered the pox. This slave, Onesismus, provided Mather with the details of variolation as performed by his relatives in Africa. However, it was actually Dr. Zabdiel Boylston who performed the procedure. Whereas Mather might have publicly supported variolation, it was not until several months after it had been in practice that he allowed his children to be variolated, and then it was done in secret.
Boylston, on the other hand, was open with his actions and suffered from repeated threats of imprisonment from the government as well as mob violence. The act of purposely giving an individual such a deadly infection was considered morally reprehensible by both citizens and public officials, regardless of its potential positive outcome. The uproar in Boston over variolation reached fevered levels, with some individuals supporting the practice and others supporting a ban. At various times the selectmen of Boston forbade individuals to enter the city for the purpose of variolation and then banned the procedure itself. On at least one occasion, in an effort to find a legal reason to imprison Boylston, his home was searched by authorities looking for individuals who had purposely been infected by smallpox through variolation.
Eventually, fear of catching smallpox “naturally,” combined with the apparent success of variolation and its popularity, forced the local government to legalize the practice. In fact, Boylston was even invited to England for an audience with the king, and he attended a number of variolation procedures during his visit.
Although variolation was a potent weapon against smallpox, it was an expensive procedure; it cost the equivalent of as much as $500 today and was initially available only to the wealthy. As a result, by the time of the Revolutionary War, many Americans were still susceptible to the disease. This posed a problem for both America’s soldiers and its civilians. Debates over variolation raged among the commanding generals of the American forces. Smallpox has a two-week incubation period, during which the individual is asymptomatic but still contagious. The possibility that individuals who had undergone the procedure might give smallpox to their fellow soldiers during the infectious incubation period and thus trigger an epidemic among the American forces initially made the procedure look too risky. In 1777, however, George Washington ordered the variolation of the entire Continental Army to prevent further outbreaks of the disease.
British forces were largely immune to smallpox, almost all having been exposed as children. Those who had not been exposed were quickly variolated. During the Revolutionary War, the British crown promised freedom to any American slave who joined their forces. Being American, the majority of freed black slaves were not immune to smallpox. Many acquired it through variolation after joining British forces.
During the contagious incubation period, black patients were allowed to wander the countryside, passing through American villages and towns and leaving smallpox in their wake. Some historians believe that the British simply did not have the inclination or the resources to care for these individuals. Others, however, believe that this represented the deliberate use of a biological weapon by the British to spread smallpox to American citizens and troops.
In July 1763 there was a documented discussion among British forces, during the French and Indian War, of distributing smallpox-infected blankets to the local Native Americans. Whether the plan went into effect was never confirmed, but within six months of the exchange, a violent smallpox epidemic broke out among the local tribes. The use of infectious diseases as weapons is not innovative. The oldest known use of a biological weapon occurred in the 14th century, when in an attempt to conquer the city of Kaffa, the khan of the Kipchak Tartar army ordered the bodies of plague (Yersinia pestis) victims to be catapulted over the city’s walls. This event is cited as the catalyst of the Black Death, a pandemic that swept across Europe starting in the 1340s and lasting a century.
The Black Death is believed to have killed as much as one-third of the European population. During World War II, the Japanese attempted to test the effectiveness of such illnesses as Y. pestis, smallpox, anthrax, and typhus as biological weapons through experimentation on an unsuspecting Chinese population. It is not beyond the realm of possibility that smallpox, like other infectious diseases, could be weaponized and released, creating a pandemic. Smallpox vaccinations are effective for only 10 years; therefore almost all of the current world population has no immunity to the disease and would be susceptible to such an attack.
In 1796, in an experiment that would never be permitted today, English doctor Edward Jenner purposely injected an eight-year-old boy with cowpox matter obtained from a pustule on a milkmaid’s hand. Following this, he attempted to variolate the boy with smallpox. The results were astonishing. Cowpox, a relatively harmless infection passed from cows to humans, provided potent immunity from smallpox. From this experiment emerged vaccinia virus, the modern and more effective vaccine for smallpox. Although there were still skeptics, as illustrated by James Gillray’s painting The Cow Pock or the Wonderful Effects of the New Inoculation, which depicted individuals who were half-human and half-bovine, some individuals, including the British royal family, submitted to vaccination. By 1840, variolation was forbidden, and in 1853 vaccination against smallpox in Britain was mandated.
Even with these advancements in prevention, smallpox continued to rage into the 20th century. According to the World Health Organization (WHO), a subcommittee of the United Nations, by the 1950s there were still 50 million cases of smallpox each year. In 1967 the WHO declared that 60 percent of the world’s population was still in danger of being exposed to smallpox, with one in four victims dying.
Controversy continued to surround smallpox well into the 20th century when an international group of scientists undertook the task of eradicating smallpox from the world permanently. In the 1950s the Pan American Sanitary Organization approved a program that allocated $75,000 annually toward the extermination of smallpox. In 1958, the WHO took over support of the program, but no action was taken until 1967. At that time the WHO approved $2.4 million for a 10-year program aimed at total eradication of smallpox.
Religion and Disease
Although scientists involved had the support of several international organizations, contention surrounded their project. Some of the most vehement protests were based on religious grounds. Numerous religions, from Hinduism to Christianity, argued that smallpox was divine intervention and judgment and that humans had no right to interfere. During the WHO’s quest to eradicate smallpox, individuals who feared that meddling would cause divine retaliation went so far as to hide those suffering from smallpox or who had not yet been vaccinated by Western doctors, making it extremely difficult to treat all cases as the program required. Others disliked the idea of mandatory vaccination, believing that freedom of choice should prevail. The program was ultimately successful, however, and the United Nations declared the world free of smallpox in 1979.
Even though there has not been a reported case of smallpox in almost 30 years, its well-guarded existence in two government facilities continues to generate attention. Governments and organizations argue over the destruction of the last known smallpox specimens. Those arguing for its elimination cite the potential for accidental release onto an unsuspecting public, as well as the need to create an environment where possession and use of smallpox are considered morally reprehensible. Those who argue for its preservation cite its potential in helping future scientists to understand viruses better and the possibility of creating more effective and safer vaccines. Additionally, they question whether it is morally acceptable for humans to purposefully incite the extinction of another living organism. These questions have been debated for almost three decades, and the debate continues.
The implications for health care and disease control policy inherent in that debate is mired in the economic impact associated with epidemics and pandemics. Much research pivots on ways to better assess how much it will cost to produce a vaccine, distribute it, and inoculate those infected. From archeoepidemiologic studies, researchers have helped the health care industry plan for the next influenza pandemic. For example, in 2009 signature features were clarified for three flu pandemics: A/H1N1 from 1918 through 1919; A/H2N2 from 1957 through 1963; and AH3N2 from 1968 through 1970. This detail is expected to contribute to both national and international plans for curbing the disease, drawing international collaboration once again into the health care policy arena.
Lawsuits investigating the line between individual rights and those of the public appear in this arena as well. The recent advent of SARS, swine flu and HIV/AIDS has heightened awareness about dual loyalty conflicts health professionals face when trying to contain epidemics and pandemics. Ethical clashes surface when, for example, a health professional decides it is in the best interest of public health to restrict individual liberties. That might include putting individuals in quarantine when infectious, or revealing to public health authorities confidential information about a patient’s sexual partners or health status. Debate continues to offer suggestions for managing dual loyalty conflicts when diseases reach epidemic and pandemic levels.
Disease and the possibility of epidemics and pandemics emerged at the same time that humans began to give up their hunter-gatherer way of life and settle into large communities and cities. Although the specific name of the disease might be in question, these events have been documented in some way since the beginning of written communication. Controversy over treatment has been widespread. Heated debates over the use of eastern prevention and treatment methods in western cultures resulted in new laws, fines, and in some cases arrests. At times religious opposition has helped to spread particular diseases when individuals have refused medical treatment. The use of infectious diseases as biological weapons is always a possibility. This practice has been roundly condemned by the international community. It continues to create fear in the general public and affects decisions about how to manage a particular disease or virus. Once a lethal or contagious disease has been contained, ethical and moral questions inevitably arise as in how to manage the specimen.
Jessica Lyons and Debra Ann Schwartz
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