The year 2018 has recently been declared our new target year for eliminating polio from the world by the World Health Organization, the Gates Foundation and Rotary International. It is clear that the next five years will pose no small challenge; we have spent over 60 years vaccinating millions of children and adults since Salk and Sabin's discovery of viable polio vaccines, and we have long struggled in particular with three countries where the virus is endemic: Afghanistan, Pakistan and Nigeria.
Photograph of a man receiving the smallpox vaccination by jet gun injector during the Smallpox Eradication and Measles Control Program in Niger, W. Africa in February of 1969. Image: Dr. JD Millar/CDC. Our difficulties in eradicating polio from these countries can be attributed to many factors - their geographic enormity, melange of cultures and religious sects, long histories of warfare and social turmoil, long-lasting simmering political resentments, and the freshly inflamed paranoia about government plots behind vaccination campaigns, just to name a few heavyweight contenders. Of course, the people residing in these countries now have every reason to be wary of health officials vaccinating their children thanks to the CIA's sham vaccination campaign that was used to ferret out Osama Bin Laden in Abottabad, Pakistan. We now have to come to grips with this ugly hiccup that has damaged both the credibility and ethos of the global public health industry. As Gates noted in his Richard Dimbleby lecture this past January, "stopping these last cases of polio in these last countries ... is among the most difficult tasks the world has ever assigned itself. The fight to eradicate polio is a proving ground, a test. Its outcome will reveal what human beings are capable of, and suggest how ambitious we can be about our future." (1)
A nomadic Tuareg girl in Mali receives a smallpox vaccination in 1967 during the Smallpox Eradication and Measles Control Program. Image: CDC. We have only one blueprint to follow in our quest to eradicate human diseases: the global smallpox campaign in the 1960s and ‘70s. This ancient virus has been a pestilence on mankind for centuries. If the infection didn't kill, then it disfigured. Thankfully, it is no longer the frightful menace that it was thanks to a worldwide smallpox eradication campaign that the World Health Assembly embarked upon in 1966.
A crowd of people in Niger, West Africa awaiting vaccination during the Smallpox Eradication and Measles Control Program in the late 1960s or early 1970s. Image: Dr. JD Millar/CDC. I was entranced when I stumbled upon a series of photos documenting the 1969 smallpox campaign in central and west Africa, showing public health officials of various nationalities vaccinating villages in one of the biggest public health battlefields. From 1966 to 1970, the Centers for Disease Control (CDC) worked with several west African governments to surveil and contain localized outbreaks of smallpox (2). Rather than using the tactic of mass vaccination within the community, surveillance of existing cases and the vaccination of close contacts and the potentially exposed was employed in a technique known as "ring vaccination." Nigeria was the birthplace of this new strategy and surely will be used again as we seek to eradicate polio (3). The recently deceased US Surgeon General Dr. C. Everett Koop remarked in a lecture given to the CDC in 1987 that
the campaign could properly be described as heroic. In 1966, smallpox was raging through South America, Asia, and Africa, [and] two and a half million people were reported as infected in 30 countries, a figure estimated to be about one percent of the actual incidence, but hundreds of public health practitioners - white and black, Arab and Jew, Russian and American - worked side by side to rid humanity of the scourge. In the African campaign, it is estimated they worked with about 4,000 local health workers, and, I might add, the smallpox campaign would not have worked were it not a grassroots campaign, it was essential that indigenous public health workers be involved in the campaign if it was to gain the cooperation of local people necessary for success. (4)
Public health authorities hunted the virus down in Kenya, Ethiopia and Somalia until the last case of endemic smallpox occurred in a young Somalian cook on October 26, 1977. After two years of surveillance, the world was declared free of smallpox.
A former Ghanian official receiving his smallpox vaccination via a jet injector gun. The photograph was taken during the West African Smallpox Eradication and Measles Control Program at the International Trade Fair, held in Accra, Ghana, on February, 1967. Image: Dr. JD Millar/CDC. These black and white photos harken back to a period in time in which vaccines were almost uniformly viewed as an axiomatic good, a lifesaving elixir that millions of people clamored for access to. The photos speak of a hard-won global achievement, one of our finest feats in medicine and public health based upon trust, collaboration and indigenous support for a local and global public health good. I suspect there's a lesson there. Resources See more great images from the smallpox campaign, as well as some superb public health posters, at the CDC's Public Health Image Library. A timeline of the history of smallpox and its vaccine. A Wiki article on Ali Maow Maalin, the young man who contracted the last case of naturally occurring smallpox in the world. His experience led him to work on the polio eradication campaign decades later in Somalia. A report on the epidemiology of tracking down Mr. Maalin and his contacts, an obituary of sorts on the world's last case of smallpox. The WHO has a series of photo galleries on the vaccination, prevention, surveillance and public health posters throughout the smallpox eradication campaign. References 1) Agence France-Presse (Jan 30, 2013) "Bill Gates urges polio eradication by 2018." Accessed online May 14th, 2013 here. 2) MO Kirk & the Task Force for Child Survival and Development (Feb 28, 2008) "Capturing an Oral History of the 1960s Smallpox Eradication Campaign in West Africa". Task Force for Child Survival and Development. Robert Wood Johnson Foundation. Accessed online May 3, 2013 here. 3) CW Choo (Sept 2007) The World Health Organization Smallpox Eradication Programme. Unpublished manuscript. Accessed online May 13, 2013 here. 4) CE Koop (Oct 29, 1987) Remarks for the Smallpox Eradication Celebration Presented to the Centers for Disease Control. Smallpox Eradication Celebration. Lecture conducted from Atlanta, Georgia. Accessed online May 13, 2013 here.