The Demon in the Freezer

  Attacks came out of nowhere. Early on, Brilliant was sent to deal with an outbreak centered in a train station in Bihar—the Tatanagar Station outbreak. He was twenty-eight years old, and Shitala Ma taught him a lesson he would never forget, for the Tatanagar outbreak blew up into the largest outbreak of smallpox in the world during the years of the Eradication, and it came as a total surprise. “I went to the train station, and I found a hundred people dying of smallpox,” Brilliant said. “I started crying. Women were handing me their babies. The babies were already dead. I heard rumors of birds carrying torn-off limbs of small children. Nothing in my life prepared me for that. I went to see the district medical officer and found him standing on a ladder in his office, alphabetizing his books. The look on his face was like a deer caught in headlights. ‘Don’t you know what’s going on?’ I said to him. ‘What can I do?’ he said.”

  The virus was traveling inside people up and down the railroad line. As the people moved, so did variola. The train station was exporting cases all over India and, in fact, all over the world. Brilliant began to see what a worldwide transportation system could do to amplify the virus globally in a very short time. He centered his effort first on the train station, where he found dozens of people with smallpox climbing onto a departing train. He started yelling at the stationmaster to stop the train. He had no authority, but the train stopped. He went to the police and told them to throw up roadblocks and quarantine the city. He closed the bus station and stopped all the buses from running, and he closed the airport. “I was just an American kid yelling,” he says. Nicole Grasset stepped in with her authority and political connections, and she put Brilliant in charge of the operation. It took six months of desperate work, millions of dollars, and hundreds of staffers and health workers to put down the Tatanagar outbreak of variola major. “That outbreak in the Tatanagar railway station gave rise to over a thousand more outbreaks all over the world, even in Tokyo,” Brilliant said. “It is not enough to think you’ve cornered all but that last one case of smallpox, because that last one case can create those thousand outbreaks.”

  Rahima

  BY 1974, smallpox was nearly gone from Asia. It had waned to a handful of cases in India and Nepal, but it was not yet finished in Bangladesh. Smallpox is a seasonal virus—it breaks out and spreads more easily when the weather is dry and cool, and it diminishes in moist, warm weather. People in Bangladesh called smallpox boshonto, which means “spring.” In south Asia, smallpox surged upward in the early spring, which is the dry season, before the summer monsoons. The eradicators mounted especially ruthless vaccination campaigns when the virus was at its ebb. In Bangladesh, they attacked the virus as hard as possible from September to November each year, when the virus seemed almost to rest—this was like killing a vampire in its sleep.

  The autumn of 1974 saw a near total victory over variola in Bangladesh. In the first week of October, only twenty-four cases of smallpox were detected in the entire country. The WHO doctors could feel the end coming, and they predicted that Eradication would occur by December.

  The summer monsoon of 1974 was fierce, causing the worst floods in fifty years to hit Bangladesh, especially in areas where there were still a few cases of smallpox. The floods set people in motion, and they settled in city slums called bustees. A few of them carried smallpox with them, and by December, variola major had begun to flicker unseen through the bustees of Dhaka, the capital.

  In January 1975, the government of Bangladesh decided to clear out the bustees. Bulldozers flattened several in Dhaka, and the police ordered everyone to go back to their home villages. Around one hundred thousand people streamed out of Dhaka. Every person in Bangladesh lives within a two-week travel time of every other person in Bangladesh. The biological situation there is no different from what it was in Egypt or the river valleys of China thousands of years ago. Since the incubation period of smallpox is eleven to fourteen days, some of the people who came out of the bustees were incubating variola and didn’t know it, and they brought it back to their villages. In February 1975, with the coming of spring, variola major roared up in more than twelve hundred places across Bangladesh. It seemed to rise out of nowhere and everywhere, coalescing out of brushfires into a viral crown fire across the country.

  The event was breathtaking in its suddenness, and it shook the eradicators to the core. The rings of containment began to fail across Bangladesh. The eradicators didn’t even know where to put rings, because variola seemed to be putting rings around them. They were seeing two hundred new outbreaks of smallpox every week. A failed ring vaccination was called a containment failure. During March 1975, there were nearly a thousand containment failures. It is said today that when the rings began failing in Bangladesh in the early spring of 1975, some of the leaders of the Eradication gave up hope. They felt that they had been wrong about variola after all, that ring containment wouldn’t work in the end, and that the evolutionary biologists might have been right in saying that no virus could be eradicated from nature.

  The program leaders in Geneva threw everything they had into the outbreak. Eradicators streamed in from the Soviet Union, Brazil, Czechoslovakia, Egypt, Great Britain, France, Sweden, and other countries. Although he had no legal authority to do so, D. A. Henderson threatened to close down the ports in Bangladesh and cut off all shipping if the government didn’t mobilize its resources and get its act together. The government of Sweden poured resources into the campaign, and OXFAM, a private charity based in Great Britain, sent large amounts of money and people. Those who arrived to help received a little bit of training and were thrown into the field. The eradicators mounted ring vaccinations across Bangladesh, and they traced cases and contacts, trying to surround the life-form, and then the summer monsoons arrived, bringing wet weather. An act of nature helped to cool the viral fire, and by the end of the monsoons of 1975 smallpox was again waning. On September 15th, in Chittagong, along the eastern side of the Bay of Bengal, a boy was found with smallpox. He was the world’s last case of variola major.

  They waited for two months to be sure, but there were no more reported cases. Finally, on November 14th, the program leaders in Geneva sent out a press release announcing that for the first time in human history the world was free of variola major.

  THE SMALLPOX ERADICATION PROGRAM team leader in charge of Bangladesh was an American doctor named Stanley O. Foster. The day after the announcement, Stan Foster received three telexes. One came from the WHO:

  CONGRATULATIONS FOR GREATEST ACHIEVEMENT.

  Another came from the Centers for Disease Control:

  CONGRATULATIONS ALL DELIGHTED.

  There was also a third telex:

  ONE ACTIVE SMALLPOX CASE DETECTED VILLAGE KURALIA . . . BHOLA.

  Bhola Island sits in the lower delta of the Ganges and Brahmaputra rivers, where their waters merge with the Bay of Bengal. Bhola Island was the place toward which Wavy Gravy and Larry Brilliant had set out four years before in their painted buses, hoping to help someone.

  Stan Foster grabbed a shortwave radio, threw a few things into a small knapsack, and left immediately for Bhola Island, traveling alone. He went to a pier in Dhaka and boarded a decrepit paddlewheel steamer called the Rocket, and took a passenger cabin on the deck. The Rocket was three hundred feet long, and it burned coal. It was a sidewheeler that had been built in 1924, and now it was a rusted hulk, jammed with humanity, chuffing and splashing down the Ganges toward the sea. Foster leaned on the rail as the boat made its way slowly along muddy channels, passing low shores lit by distant gleams of oil lamps. A waxing moon climbed across the stars, and he turned into his berth and slept. The air developed a hint of salt, and the Rocket entered an estuary, and shortly after sunrise the boat arrived at the port of Berisal, the end of the line, where Foster disembarked. He boarded a smallpox speedboat—an outboard motorboat run by the Eradication program—and it took him down across a vast brown bay, dotted with wooden sailing craft. He passed canoes and lateen rigs and catbo
ats and square riggers, with cotton sails patched with cloths of bright colors; and he came to Bhola Island. It is thirty miles long, and it then contained a million people but nothing like a city. The speedboat stopped at a pier, and Foster disembarked. He was greeted by a team of local eradicators.

  The island was a sandy mudflat where rice grew in profusion. There were palm trees and banana trees, and little houses of thatch, and lots of people everywhere. Foster and the local team got into a Land Rover and headed down a rutted road. The road got too muddy for the vehicle, so they parked and walked to Kuralia. They were always in the presence of people, working in the rice fields, crowding the paths. “You can’t be in private in that country,” Stan Foster said to me.

  Local health workers led Foster and his team to a house belonging to Mr. Waziuddin Banu, a poor man who could neither read nor write. He owned no land but worked the land for others. Banu’s house had a thatched roof and walls made of woven fronds of palm.

  It was dark inside Banu’s house. “I go in the house,” Foster said, “and I can’t see any cases of smallpox. Then I see this burlap sack in the corner, with a foot sticking out. It was a little kid covered with classical pox—a moderate case, not severe.” The victim was a little girl, three years old, named Rahima Banu. She was frightened of Foster, and had popped herself into the sack when he came in the door. Rahima had scabbed over, and most of her scabs had already fallen off. She had caught the virus from her uncle, a ten-year-old boy named Hares. Rahima, Hares, and a few other people with smallpox in the village had been diagnosed by an eight-year-old girl named Bilkisunnessa. She reported the cases to a local health worker, and she eventually collected a reward of sixty-two dollars from the WHO—a fortune for a girl on Bhola Island.

  Stan Foster raised Dhaka on the radio and told his people that he had confirmed a case of smallpox. That night, an eradicator named Daniel Tarantola put together a large team in Dhaka, with twenty motorcycles and barrels of gasoline, and they set out for Bhola Island aboard the Rocket. The team organized a ring vaccination on the island, and they traced contacts, and vaccinated everybody who might have been exposed. In succeeding weeks, they searched all over the island for new cases, but they didn’t find any. Now variola major was really finished on earth. The hot type of smallpox had been uprooted.

  When Stan Foster was with Rahima Banu, he took a bifurcated needle and used it to gently lift six scabs from her legs and feet. He tucked them into a plastic vial that had a red top. The removal of the little girl’s scabs would not have hurt much, because they were falling off anyway. Each of Rahima’s scabs was a brownish crust about the size of the worn nub of a pencil eraser.

  When he returned to Dhaka, Foster gave the scabs to a virologist named Farida Huq, and she confirmed they were smallpox, and then she put the vial of Rahima’s scabs into a metal canister, along with a sheet of paper identifying the specimen. The canister went into a cardboard mailing tube and was sent to headquarters in Geneva. A secretary named Celia Sands handled all the smallpox samples—largely scabs in tubes—that were sent in from the field. She opened the packages on a table in the work area in the middle of the SEP cubicles, took out the red-topped plastic tubes full of scabs, and entered the information about them into a log. She was getting smallpox boosters once a year. (“Now, when you think about how we handled the specimens, it’s so different from the way it’s done today,” she said to me. “Nothing ever happened, though.”) After she had logged and inspected them, she sent the samples on to one of two smallpox repositories, either to the CDC or to the Institute for Viral Preparations in Moscow. These two places were known as WHO Collaborating Centres. Sands alternated sending samples to one or the other, so that the Americans and the Russians would end up with roughly equal amounts of scabs.

  The smallpox at the Moscow Institute was cared for by a fluffy-haired, somewhat stout pox virologist named Svetlana Marennikova. She was highly regarded among pox experts, who found her scientific ideas provocative and solid.

  Rahima’s six scabs ended up at the CDC, where around Christmas of 1975, a pox virologist named Joseph Esposito transferred them with tweezers into a little plastic vial, smaller than a person’s pinky. With an extrafine Sanford Sharpie pen, he wrote RAHIMA on the vial, added some other identifying data, and placed the vial in the CDC’s reference freezer containing smallpox strains.

  The end of variola major, autumn 1974 to autumn 1975. These successive maps of Bangladesh are like frames of a movie that show the last blowup and final eradication of variola major from the human species. You can see rings of containment around outbreaks, as well as “containment failures”—smallpox bursting out. As the virus wanes under vaccination, it moves toward the east and south, and finally it ends up on Bhola Island.

  Courtesy of Stanley O. Foster, Center for Public Health Preparedness and Research, Rollins School of Public Health, Emory University, from The Eradication of Smallpox from Bangladesh, by A. K. Joarder, D. Tarantola, and J. Tulloch (New Delhi: WHO South East Asia Regional Office, 1980).

  The strain of variola major that came from those scabs is known today as the Rahima. All six of her scabs are said to have been used up in scientific research, but the Rahima exists, frozen in small plastic vials full of translucent white ice, which looks like frozen skim milk. The milkiness is caused by vast numbers of particles of the Rahima strain, which have been grown in virus cultures and are now suspended in the ice. The Rahima sleeps in a freezer and will never die, unless and until the human race decides to end its relationship with variola, and puts the Rahima and all other smallpox strains to death.

  The weak strain of smallpox, variola minor or alastrim, continued to run in chains of transmission around the Horn of Africa. The eradicators focused their attention there. On October 27th, 1977, a hospital cook in Somalia named Ali Maow Maalin broke out with the world’s final natural case of variola. They vaccinated fifty-seven thousand people around him, and the final ring tightened, and the life cycle of the virus stopped.

  A Slit Throat

  IN THE LATE SUMMER of 1978, less than a year after Ali Maow Maalin contracted the last naturally occurring case of smallpox, Janet Parker, a medical photographer in Birmingham, England, became sick. Confined at home, she developed a blistering rash all over her body. Her doctor believed she was having a bad reaction to a drug. Parker lived alone, and she became too ill to care for herself. Her seventy-seven-year-old father came to her house, helped Janet into his car, and drove her home to stay with him and her mother. Parker grew sicker, and her parents took her to the hospital, where doctors were stunned to discover that she had smallpox.

  Mr. Parker came down with a fever twelve days after he had driven Janet home in his car, and as he was breaking with variola he died of a heart attack. Janet died of kidney failure in early September. She had been vaccinated for smallpox as an adult, twelve years before she died, but her immunity had worn off. Janet’s mother broke with smallpox and survived; she was the last person on earth who is known, publicly, to have been infected with variola. In Somalia, WHO doctors described the deaths in the Parker family to Ali Maow Maalin, the hospital cook. They say he burst into tears. “I’ll no longer be the last case of smallpox!” he said to them.

  Janet Parker had worked in a darkroom on the third floor of a building at the medical school of the University of Birmingham. One floor below her darkroom, and down the hall some distance, a smallpox researcher named Henry Bedson was doing experiments with variola. Bedson was a thin, gentle, youthful-looking man who was internationally known and had established personal friendships with many of the eradicators. A team of investigators from the WHO was never able to pin down exactly how Janet Parker became infected, but they believed that particles of the virus had floated out of Bedson’s smallpox room, drifted through a room used for animal research, had then been sucked into the building’s air-vent system, had traveled upward one floor, passed through a room known as the telephone room, passed through two more small rooms, and f
inally gotten inside Parker’s darkroom, and had lodged in her throat or lungs.

  On September 2nd, as Janet Parker lay desperately ill, Henry Bedson was discovered lying unconscious in the potting shed behind his house. He had slit his throat with a pair of scissors, and much of the blood in his body had drained out. He died five days later, despite transfusions.

  When Bedson slit his throat, the eradicators woke up to the fact that although the disease was gone, the virus wasn’t, and they stepped up their efforts to gain control of all the known stocks of smallpox in the world. They felt that as human immunity to the virus waned year by year, the potential for laboratory accidents was growing.

  In 1975, at least seventy-five laboratories had frozen stocks of smallpox virus. Poxviruses, including smallpox, can survive for many decades in a freezer without damage or loss of infective potency—probably for at least fifty years. A freezer with a few vials of smallpox in it could become a biological time bomb. In 1976, a year before the last natural cases of smallpox occurred, the WHO formally asked all laboratories holding smallpox to either destroy their stocks or send them to one of the two Collaborating Centres. The WHO had no legal power to compel anyone to give up their smallpox, but D. A. Henderson and the others were tough and persistent. One by one, the laboratories that were keeping smallpox sent their samples to America and Russia or destroyed them or said they had destroyed them.

  Vault

  TODAY, VARIOLA EXISTS OFFICIALLY in only two repositories, the Collaborating Centres. One of the repositories is the Maximum Containment Laboratory at the CDC in Atlanta. The other repository is in Russia. When scientists handle variola, international rules require them to wear full space suits and to be inside a sealed Biosafety Level 4 containment zone. The WHO forbids any laboratory from possessing more than ten percent of the DNA of variola, and no one is officially allowed to do experiments with smallpox DNA. Variola is now exotic to the human species, highly infective in humans, lethal, and difficult or impossible to cure. It is generally believed to be the most dangerous virus to the human species.