Smallpox

The Fight to Eradicate a Global Scourge

David A. Koplow

Introduction

The virus responsible for smallpox—a tiny creature known as variola—has been a despised enemy of civilizations around the world. Over a period of at least three millennia it was second to none in inflicting human pain, suffering, and death. By some estimates, smallpox killed as many as 500 million people during the twentieth century alone, and as recently as thirty years ago, it was still at large in over thirty countries, attacking some fifteen million people annually and killing two million of them.

Through history, we have battled this foe with incantations, poultices, quarantines, and vaccinations. After struggling to contain it, we have at last conquered the disease globally and placed the last acknowledged vestiges of the virus in high-security confinement. Now, under the auspices of the United Nations, humans may be about to take a final, irreversible, step: to exterminate the last remaining captive samples of the smallpox virus. Thus, a quarter century after smallpox as a disease was wiped off the face of the earth, after additional years of painstaking struggle and research, the last two stockpiles of the causative virus (at least the last two that we know about)—stored in 1/2-inch high plastic vials in 70° Celsius liquid nitrogen baths inside secure isolation chambers at the Centers for Disease Control and Prevention in Atlanta, Georgia, and at the Russian State Research Center of Virology and Biotechnology near Novosibirsk—are targeted for destruction.

If activists in the World Health Organization and in many governmental and private institutions around the world have their way, then within the next few years all the known variola samples, all the various strains, and all the residual infective materials will be inserted into an autoclave—a small, airtight laboratory sterilization furnace. The jets will be ignited, raising the temperature to 120° Celsius for forty-five minutes, and the process will be repeated. Then the vials that have housed the virus for so long will themselves be incinerated. In the end, there will be no tangible legacy at all of one of the most pernicious killers in earth's history.

We are thus on the precipice of a momentous decision: human beings are about to conduct the world's first deliberate extinction.

Extinction carries a certain irresistible cachet. The finality of —eradicating not just a particular individual but an entire species arouses human curiosity and wonderment. The notion of permanently and deliberately divesting the planet of a discrete life form, whether a terrifying dinosaur or an elusive aquatic plant, is—as it should be—both humbling and awe inspiring.

Of course, extinctions occur all the time: the earth loses dozens, if not hundreds, of species every year, usually without public fanfare, often without even human cognizance. We lose flora and fauna we have rarely seen, hardly studied, and never catalogued. Many of these collective deaths, perhaps most, are at least partly attributable to human activity. We overhunt some species; we irrevocably destroy the critical habitats of others; pollution drives still more into the abyss. In some instances—dodo birds, carrier pigeons—the extinction has become a notorious case study for subsequent generations to abhor. In a few instances—bald eagles, snail darter—a monumental social enterprise has been launched to preserve the endangered species, occasionally becoming at least partially successful. In most instances, however, humans little note nor long remember the passage of a dying breed.

With the eradication of smallpox, however, human accountability for the destruction of another kind of creature may become not only self-conscious but deliberate. This book is an analysis of that imminent, irrevocable action, investigating the facts underlying it, exploring the public values supporting it, and critiquing the decision-making apparatus leading up to it. The inquiry is necessarily both interdisciplinary and international in focus, examining the different categories of thought and activity that have led us to the brink of this decision. To understand our collective posture toward variola, and to think rationally about what to do next, we need to synthesize lessons from medicine, biology, military science, environmentalism, international organizations, and ethics. To decide whether to exercise the awesome power that technology and conscientious labor have now afforded us—and to decide what precedent to establish for the next time we are confronted with a comparable dilemma—we should pause now to deliberate a very delicate social choice.

In deciding whether to eradicate smallpox, the world community must address diverse and fundamental questions. Each of the next six chapters analyzes one key dimension of the story of smallpox. Chapter 1 scrutinizes the medical issues, beginning with a sketch of the history of smallpox and humankind's battle against it. It traces the devastating effects of smallpox across continents and through centuries. It also outlines the convoluted course of antismallpox activity, from ancient deity worship to Lady Montague's sixteenth-century invocation of variolation, Edward Jenner's eighteenth-century discovery of vaccination, and Dr. Donald ("D.A.") Henderson's twentieth-century leadership of the dramatic and successful eradication campaign.

Chapter 2 then turns to the biological dimension, posing fundamental questions such as: What is a virus? Is it alive, as a distinct species? What might we learn from continued research on this creature—a pathogen that afflicts only human beings, with no known animal or plant reservoir? And what more could we do to protect ourselves against a future outbreak of it? The chapter also presents, in layperson's terms, an analysis of modern research into genetic engineering, surveying whether futuristic DNA-splicing techniques and cloning technology might have implications for variola preservation.

Next, chapter 3 turns to the military dimension. It profiles how biological weapons agents, including the smallpox virus, have been conceptualized, and occasionally used, as weapons. Certainly disease has played a huge, albeit largely unintentional, role in hostilities: in virtually every international or internal conflict, more people (civilians and soldiers alike) have been felled by illness than by bullets or bombs. Pestilence has shifted battles, won wars, conquered empires, and changed history. However, most military authorities in the United States and elsewhere eventually came to dislike and distrust biological means of warfare, concluding that germs are simply too unpredictable and too uncontrollable for battlefield applications, and they were removed from most countries' active arsenals, unilaterally and voluntarily, more than two decades ago. Yet within the last few years, the revolution in genetic engineering has threatened to reverse that self-restraining judgment once again, and new incarnations of biological weaponry might prove to be far more effective and attractive—for terrorists no less than for regular armies. The upheavals on and after September 11, 2001, provide another fresh impetus for reexamination of the specter of unconventional warfare, such as smallpox bioterrorism.

The environmental dimension is the topic of chapter 4, which considers the extent to which the new, but increasingly entrenched, planetary regard for protection of biological diversity may inform the eradication decision. As we have come to appreciate the importance of husbanding our planet's scarce resources, we recognize the magnificent kaleidoscope of species—and their dazzling array of genetic variation—as carrying irreplaceable human value. Already legions of treaties, principles of customary international law, and domestic statutes constrain our heretofore clumsy disregard of other species. Even if these enactments turn out not to be legally binding on the novel question of preservation or destruction of a miniature creature such as a virus, they still exemplify important principles, values, and intellectual constructs that should inform our choices.

Chapter 5 discusses another, very different type of international institutional or organizational process issue: the role of the United Nations, specifically the World Health Organization (WHO), in deciding the fate of the smallpox virus. Who, in this world of independent, sovereign states and an increasingly dense thicket of amorphous multilateral nongovernmental organizations, has the legal authority to make the final decision for all humankind in this type of life-and-death matter? How has, and how should, the WHO bureaucracy and governing institutions engage this challenging issue, and what procedures should it employ in order to act wisely for us all?

Chapter 6 then confronts some of the profound ethical aspects of the smallpox eradication campaign. What social lesson will we teach future generations by our dealings with variola? What is the precedent we are establishing for the next time this type of deliberate extinction opportunity arises (which may not be far off)? What moral doctrines should we employ to evaluate whether the virus should be sustained? What substantive criteria are relevant to this type of determination, as humans, in a new way, opt to play God—or perhaps to play Dr. Frankenstein? These questions admit of no easy answers, but they must be asked and some irrevocable lines must be drawn.

To separate these distinct "dimensions" in this way is, admittedly, somewhat artificial. In this complex and unprecedented question, everything is connected to everything else, and the boundaries we have constructed between various intellectual disciplines are ill-defined and porous. Still, it may be useful to deconstruct the gnarled mass of issues that bear on this decision and tease out the identifiable strands for separate consideration.

The next two chapters shift gears a bit. Chapter 7 presents the case for extermination, marshaling the arguments in favor of exterminating variola. It adduces five leading genres of arguments that can be asserted in support of the WHO's eradication decision, drawing freely upon the policy and technical considerations advanced in recent years by a variety of proponents. Chapter 8 presents the brief in opposition, assembling the best possible case against extermination. It weaves together five contrary arguments, again concentrating a variety of policies and preferences adduced by participants and observers. Together, these two presentations represent a scholarly and pragmatic debate drawing on all the preceding chapters, one that should help shape public policy dialogue.

Chapter 9 presents recommendations and concluding thoughts. My own "bottom line" is that I would not destroy these final exemplars of the smallpox virus. I would preserve them not out of a false sentimentality for a most undeserving scourge, nor simply out of an ethical concern that it is wrong for humans to play God in this way—although I take that to be a serious matter. Rather, I reject the hubris implicit in the conclusion that we no longer need the variola virus because our studies have already taught us everything we will ever need to know about it. I would retain these small reservoirs of DNA, just in case, as a relatively inexpensive form of biodiversity insurance, against the day when we may need this reprehensible scrap of genetic material to serve a noble end. Accompanying that conclusion are recommendations for the WHO, the United States, and other key actors on related policy matters ranging from counterterrorism initiatives to public health investments.

As far back as 1986, the WHO (or a cadre of experts within the institution) decreed that the variola residues should be promptly destroyed. Their target date was December 31, 1993—the first of a series of deadlines that have slipped unremarkably past while the virus samples linger on. The most recently established date (once described as the "final" extension for variola) was December 31, 2002—a day that has now been rendered moot, as have all the others, and will pass without dispositive action. The Bush administration has declared its opposition to any such destruction in the foreseeable future; its Russian counterparts have eagerly concurred; and the WHO bureaucracy, and its constituent member states, are still struggling to decide how to respond to the two dominant players' desertion from an erstwhile global consensus. No new target date for eradication has yet been established, but the WHO member countries still earnestly seek a prompt final resolution.

It is also important to note that the WHO may fail in any case to achieve its objective. Even if a strong global consensus is manifest, even if all countries declare their willingness to exterminate the last remaining variola samples, and even if the American and Russian repositories are, in fact, incinerated on schedule, all we can deal with in this way are the known stockpiles. All partisans acknowledge that other variola stashes may exist—hidden away by incompetence or malevolence—with the possibility of reemerging in some horrible scenario. Our policymaking, and our appreciation for the grand symbolism of our choices, must therefore be informed by that reality, and the rhetoric of our articulated goals modulated to that extent.

Stepping back just a bit, the variola question provides an opportunity to reflect anew that humankind has always struggled with, and against, nature, seeking to shield ourselves and our progeny from environmental threats. We have tamed rivers, felled forests, and established our dominion over the animals of the land and the fishes of the sea. We have waged ceaseless (but often fruitless) war against an array of biological pests: rodents, insects, and, now, viruses. But the step we contemplate taking with smallpox extends beyond merely resisting nature's forces, beyond domesticating a rival species or confining it to a circumscribed ecological niche. Here, we seek not only to control or defeat it; we intend to destroy it completely.

There is also a lesson here about risk. People have a difficult time thinking clearly and coherently about dangers that have a very low probability of occurrence but a very high cost if they do come about. Here, we are compelled to identify, assess, and trade off risks of very different types: bioterrorism, genetic engineering, laboratory accidents. How can we evaluate those risks in a manner that is rational, fair, and sensitive to all constituencies? In the main, the modern struggle against smallpox has been one of the finest achievements of the human race: we have demonstrated generosity, tenacity, inventiveness, and aplomb that have known no borders. In addressing the final step, the extinction of the last remaining viruses, how can that noble tradition best be sustained?

Over thousands of years the variola virus has tested our stamina, our intelligence, and our collective sensitivity. In struggling for a way to think coherently about this controversy, we have tended to fall back on familiar analogies, such as capital punishment: variola is depicted as an unrepentant convicted murder, now lingering on death row, with WHO considering whether to grant yet another stay of execution. That metaphor certainly has its appeal, but its explanatory power has limits, too. Now, we must face the reality that nothing in our collective experience is a valid model for organizing ourselves on this issue: it truly is a case of first impression. But just as surely, it will not be the last occasion for humans to confront these weighty issues.