What the world learned in eradicating smallpox: Unity mattered

Forty years ago, the world celebrated the vanquishing of a formidable foe, smallpox, which had maimed and killed millions for centuries. On May 8, 1980, the World Health Organization declared that smallpox had been eradicated.

That milestone, reached while the Cold War still raged, is an example of what the public health world can achieve when it works together — and is particularly resonant in the midst of the coronavirus pandemic. The campaign against smallpox took 21 years and required not just vaccinations but tracking and isolating new cases.

“We learned a lot of lessons in smallpox, but one of them is the absolute necessity of coalitions,” William “Bill” Foege, one of the architects of the smallpox eradication program, told STAT.

“This was all done during the Cold War. The Soviet Union and the United States working cooperatively … trying to convince the WHO to take this on as an objective,” Foege, 84, recalled. “It required the WHO. You had to have global cooperation.”

Much of the world is cooperating against Covid-19 today. Earlier this week, for instance, global leaders pledged $8 billion to fund a coronavirus vaccine. The United States did not participate in that effort, however, and under the direction of President Trump, has suspended funding to the WHO, citing concerns about its handling of the pandemic response.

Stewart Simonson, an American who is currently serving as a WHO assistant director-general, marvels at the smallpox accomplishment. Simonson worked for years with the late D.A. Henderson, decades after Henderson and Foege led the smallpox eradication effort.

“It just struck me then, as it strikes me today, as not just a great achievement, but the greatest achievement of the multilateral system,” Simonson said of effort against smallpox, still the only human virus consigned to history.

“In the first 80 years of the 20th century alone, 300 million people are thought to have died of smallpox. It was a scourge,” Simonson said. A legacy of the program was the expanded program on immunization — known in the public health world as EPI — which vaccinates children around the world against a range of diseases such as measles, polio, diphtheria, and tuberculosis.

“Think of the children who have lived healthier lives because of that. It’s like an inflection point in public health,” Simonson said.

Foege, who was director of the Centers for Disease Prevention and Control from 1977 to 1983, is credited with figuring out that targeting the people who had smallpox and vaccinating and quarantining their contacts could stop spread of the disease. The approach was an alternative to mass vaccination.

Though there is currently no vaccine to prevent Covid-19 infection, the surveillance and containment approach, as it is called, forms the basis of the recommended strategy to contain the new disease. Test to find cases. Identify everyone they’ve been in contact with. Isolate the sick and quarantine the contacts while they might be incubating the disease.

“You hear with coronavirus about contact tracing and how difficult that is. That’s what we were doing with smallpox,” Foege said, noting back then the work was done without computers or cellphones.

In May of 1974, in a single state in India, 1,500 smallpox cases were being identified every day. “And every one of those cases involved a new investigation. So 1,500 investigations a day,” Foege said. “I’m surprised now, with all of our communications and things, that people think tracing Covid-19 is too difficult.”

Within a year of using this containment approach, transmission in the state, Bihar, stopped, Foege said.

Foege, who is a legend in global health circles, called the idea of defunding the WHO “illogical.” He warned the United States risks isolation on the global health stage if it pursues this approach.

Jeremy Konyndyk, a senior policy fellow at the Center for Global Development, agreed. The Trump administration has criticized the WHO for its response effort and also spread the unproven theory that the virus came from a Chinese lab. Other countries have raised questions about the origins of the virus, Konyndyk noted, but none has joined the United States in suspending funding to the global health agency.

“The U.S. is the only country that is hammering the WHO for its early performance,” he said.

Working within the international system is a better way of achieving ends than being on the outside sniping, he suggested.

“If what you want is other countries to put money towards things you care about, the way that you do that is you exert influence within the multilateral system,” Konyndyk said. “And we used to be pretty good at that.”

— An earlier version of this story incorrectly spelled the name of Stewart Simonson.