Plagues in World History (18 page)

Even when Native American responses to disease are similar to those in other cultures, the fact that these responses were not allowed to express themselves in 84 y Chapter 2

isolation but were impinged upon by the responses of a completely different culture changes the dynamics of the outcome. A good example of this is the typical explanation of disease as the product of the displeasure of the gods, an outlook that natives in the New World shared with the new arrivals from the Old World. As if the wrath of one’s own gods was not bad enough, Native Americans were also told that the rival Christian God likewise caused disease, so that they were then caught in an epidemiological catch-22, being subject to some kind of epidemic punishment no matter whom they worshipped. I think it also possible that the differential mortality and morbidity with which a disease like smallpox afflicted Native Americans as compared with Europeans (for whom, at least during the Middle Ages, smallpox seems to have behaved like a relatively mild child-hood disease) encouraged New World societies to view their gods as defeated by the one God of the Christians,26 especially since they already viewed their own gods as sometimes battling each other, such as the Aztec legend of the defeat and banishment of Quetzalcoatl by Tezcatlipoca.

Another parallel set of responses that actually turns out to be dissimilar is the tendency to flee any occurrence of a disease, even when it occurs among one’s own family, which we have seen was widely reported in Europe during the Black Death and was likewise observed among Native Americans during smallpox epidemics. (Only in the Muslim Middle East does there seem to have been a cultural antipathy
against
flight.) Yet, here again, the experience was not the same.

Not only did flight threaten to disrupt the traditional communal bonds holding together a society, as Giovanni Boccaccio complained it did in Florence during the Black Death, but also to this was added in the New World the humiliating spectacle of some Europeans, such as the Jesuit missionaries, being more charitable toward the natives than the natives themselves as they stayed behind to nurse the sick. It is quite likely that European medicine at this stage was no more effective in treating smallpox than native healing methods. Although some have blamed the traditional indigenous practice of resorting to sweat lodges alternat-ing with cold baths or immersions in lakes for fatally exacerbating the illness, European observers tended to view any kind of bathing with suspicion on both moral and humoral grounds, while some European doctors, such as a Master Bernard of Frankfurt and Theobaldus Loneti of Besançon, advocated their own sweating regimens as a cure for plague.27 But because European healers in the New World such as the Jesuits had the great advantage of being seemingly immune to a disease like smallpox, they were able to fill a void left by native sha-mans and
hechicheros
who had failed to cure illnesses with their own brand of magic and so were able to persuade many natives to abandon their own belief systems, as one study of the impact of disease upon native culture in northwest-ern New Spain has found. In addition, agents of colonialism such as the Jesuits Smallpox y 85

already had an ideological framework in place with which they could readily explain and rationalize epidemics of smallpox.28

Even as the symbiotic relationship between disease and cultural imperialism was playing itself out in the New World, smallpox was once again gaining in virulence in the Old World, perhaps as a result of the reimportation of a new Variola major
strain from the Americas back to Europe. From the second half of the sixteenth century, smallpox epidemics started to recur more frequently, until by the close of the seventeenth century smallpox had become the predominant disease in Europe, apparently bypassing plague, leprosy, and syphilis as the leading killer throughout the Continent. Much of this was aided by the fact that urban populations were rising and warfare was incessant, both of which facilitated the spread and prevalence of a disease like smallpox.29 During the eighteenth century, however, Europeans finally acquired the tools to combat the rising tide of smallpox: the century was bracketed by the introduction of the technique of inoculation at its beginning and the discovery of vaccination by its end.

Inoculation, also known as variolation, is the deliberate introduction of a weakened form of smal pox into the patient in order to induce a mild case of the disease and so create immunity to it and was widely practiced in Istanbul toward the end of the seventeenth century, after the Turks learned of it from the Chinese or the Persians. By the dawn of the next century, several European observers in Istanbul began communicating their newfound awareness of the practice, the most famous being Lady Mary Wortley Montague, wife of the British ambassador to Turkey, who eventually introduced it to England in 1721. Around this same time, inoculation also found its way to the American colonies, when the Reverend Cotton Mather of Boston learned of the practice from his West African slave, Onesimus, and from other slaves in Boston who reported that it was long and widely practiced in western Africa. Later, inoculation was to play a role in the American Revolution, when General George Washington had his soldiers inoculated in order to forestall germ warfare from the British, who were generally more immune to the disease.30

Then, on May 14, 1796, Dr. Edward Jenner performed his famous vaccination of a patient, an eight-year-old boy named James Phipps, with cowpox lymph taken from a sore on the hand of a milkmaid, Sara Nelmes. This was by no means the first recorded vaccination, but it was the most influential in that Jenner demonstrated that it could induce immunity to smallpox without the side effects of inoculation. Indeed, it is even claimed that vaccination can be traced all the way back to ancient Ayurvedic medicine in India. During the nineteenth century, vaccination became compulsory in many European countries, even though there was opposition mainly on the grounds of safety in terms of other diseases that might be communicated with the vaccine, and on the grounds of efficacy in that the immune response generated by vaccination was not lifelong, as in the case of inocula-86 y Chapter 2

tion. Ironically, the drastic decline of smallpox in Europe only facilitated antivac-cinators’ objections due to the waning urgency of vaccination itself.31 These objections were largely overcome through the development of better vaccines and revaccination programs. It should also be pointed out that, despite the advent of vaccination, smallpox continued to devastate “virgin soil” populations throughout the nineteenth century in the Americas, the Pacific Islands, and among the Ab-original peoples in Australia, while a more virulent strain of the disease wreaked havoc in West Africa even though it had been endemic there for centuries.

Resistance to nineteenth-century vaccination programs was encountered by European governments not only at home but also in its colonies abroad. A prime example of this is the British experience in India, where expectations were high that vaccination would be gratefully and joyfully received by natives as a benevolent marvel of Western medicine and so help cement imperial political rule in the country. But as with its later measures against the Third Pandemic of plague, the British disastrously underestimated the extent of native resistance to vaccination.

These included some Hindu religious objections that were unique to India, such as that arm-to-arm transmission of the cowpox lymph might violate caste taboos and reverence for the sacred inviolability of the cow, but they also shared some of the same concerns that motivated protests in Europe, such as the unreliability of the vaccine. India also had a strong and ancient local tradition of variolation and of religious rituals centered on the smallpox goddess, Sitala. Even though British medical authorities regarded native inoculators, known as
tikadars
, to be their rivals in terms of implementing their own vaccination programs, eventually they were forced by fears of widespread political unrest to adopt a more low-key, collaborative policy whereby they recruited
tikadars
as vaccinators. It was not until the end of the century that vaccination because more available and widespread in India.32

Another “vaccination revolt” in a former European colony famously occurred in Rio de Janeiro in Brazil in November 1904. Here the European-influenced government of Rodrigues Alves, advised by a young bacteriologist named Oswaldo Cruz, regarded vaccination as a humanitarian blessing of the new, modern, scientific approach to disease, just as the British did in India. However, the city’s Afro-Brazilian population preferred its native practice of variolation inherited from Africa, while socialists and other political opponents of Brazil’s oligarchic regime protested the “sanitary despotism” of such public health measures being imposed by the government.33 Antivaccination sentiments have not gone away even in this day and age; during the writing of this book, I saw a bumper sticker that said, “Say No to Forced Vaccinations.” Today, the issue primarily concerns vaccines developed for influenza, of which more will be said in chapter 5.

The final chapter of the history of smallpox is the successful eradication of the disease during the twentieth century. By the time the Smallpox Eradication Pro-Smallpox y 87

gram was announced by the World Health Organization (WHO) in 1966, with a goal of global eradication in ten years’ time, smallpox was still endemic in South America, sub-Saharan Africa, and the Indian subcontinent and archipela-gos of Southeast Asia. Almost miraculously, the program completed its eradication campaign on schedule, with the last case of
Variola major
reported in Bangladesh in 1975 and of
Variola minor
in Somalia in 1977. Complete, certifiable eradication was finally announced by WHO in 1979, which was achieved largely by a “surveillance-containment” strategy that focused only on vaccinating those who were in contact with known cases of smallpox.34

Today, the only controversy that still exists with respect to smallpox is whether or not to destroy the last known remaining stocks of the virus at the U.S. Centers for Disease Control in Atlanta and at the Russian State Research Center of Virology and Biotechnology in Novosibirsk. Originally, WHO had scheduled the final execution of the virus to take place on June 30, 1999, but a stay of execution was granted indefinitely at the behest of the administration of former U.S.

president George W. Bush in 2001 in the immediate aftermath of the September 11 terrorist attacks. On the one hand, execution makes sense if only to avoid tragic mishaps with the virus, such as happened in Birmingham, England, in 1978, when the virus escaped from a research laboratory there, killing one person and driving another, the man in charge of the laboratory, to suicide. There is also the fear that some of the remaining supplies could somehow end up in the wrong hands and become an agent of bioterrorism, in which the virus would act almost like a virgin soil epidemic, since it has been three decades now since anyone got the disease or has been vaccinated. The dangers of even waste material from the laboratory was illustrated in 2000, when eight children at Vladivostok in Russia were diagnosed with a mild case of smallpox after playing with glass ampoules containing expired smallpox vaccines at the city’s garbage dump. On the other hand, others, including Donald Hopkins, perhaps the greatest authority on smallpox, who has authored a history of the disease and participated in the Smallpox Eradication Program, argue for keeping stocks of the virus alive for research purposes and as insurance in case somehow another epidemic should break out that would require developing more or better vaccines. In 2004, for example, WHO approved genetic manipulation of the smallpox virus in order to develop drugs for treating the disease, once again in response to renewed fears of possible bioterrorism attack.35 (To date, no cure is available for smallpox, only a vaccine.) All this shows that, once again, smallpox plays a differential role in history, even at the very putative end of its existence, when its fate is in the hands of only two countries that still have stocks of the virus. We can only hope that, regardless of the outcome of this debate, smallpox as a disease will remain con-signed to the pages of history.

C H A P T E R 3

y

Tuberculosis

Tuberculosis (TB) is an ancient disease that probably emerged in humans with the domestication of animals some ten thousand years ago at the start of the Neolithic period. Tuberculosis, like smallpox, is a crowd-dependent disease, needing a critical mass of victims in order to become endemic in a population; this would have been achieved in both animals and humans only when herds and cities would have created the prerequisite densities and contacts required.

It seems that the crossover from animals to humans in tuberculosis occurred with our domestication of goats rather than cows, since the goat strain of Mycobacterium bovis that causes the disease in animals is more closely related to the human bacterial agent
Mycobacterium tuberculosis
than is the strain in cows.1 However, it is entirely possible that tuberculosis occasionally afflicted Paleolithic man, since
Mycobacterium tuberculosis
has been discovered in the remains of a seventeen-thousand-year-old bison.2 As with smallpox, the physical evidence of tuberculosis has been found in ancient Egyptian mummies and other Neolithic burial remains, particularly in the bone decay produced in their spines, giving them a humpbacked appearance. The ancient Greeks called the disease
phthisis
, which Hippocrates in his
Aphorisms
described as a wasting illness characterized by such symptoms as the coughing up of bloody sputum, loss of hair, and diarrhea. In the Middle Ages, tuberculosis was commonly referred to as scrofula or the “king’s evil,” in which the swelling of the neck caused by inflamed lymph nodes was believed to be curable with the miraculous touch of the royal hand, as was claimed by both the kings of France and England.