The greatest killer: smallpox in history Donald R. Hopkins Chicago and London: Chicago University Press; 2002 Originally published as Princes and Peasants: Smallpox in History, 1983 380 pp US$18 (paper) ISBN 0-226-35168-8
It cannot have escaped anyone's notice that the horrific events of Sept. 11, 2001, have been co-opted by many to foster a number of political, economic and even scientific agendas. A recent article in the New England Journal of Medicine, for instance, noted that, post 9/11, “developing public health strategies to counter bioterrorism threats from smallpox is a high national [i.e., American] priority.”1 The post-9/11 context does much to explain the relaunch of Donald R. Hopkins' history of smallpox, first published 20 years ago as Princes and Peasants: Smallpox in History. It now appears with a revised title and a new introduction, in which Hopkins suggests that “we face the prospect that this ancient virus may be resurrected, not as a naturally occurring disease but deliberately, for use as a biological weapon.”
The vanquishing of wild smallpox to one or two (no one really seems to know) sophisticated laboratory freezers surely is one of the great success stories of the 20th century. Make no mistake: as Hopkins reminds us, it did not come easily. Buttressed by a chronology, index and extensive bibliography, his account presents a painstakingly thorough outline of humankind's struggle with this “most terrible of ministers of death,” up to and including the author's own role in the WHO's “war” on smallpox.
The Greatest Killer is broken into chapters that trace the known history of smallpox in numerous geographic and cultural contexts, from ancient China to pre-Confederation Quebec. That smallpox did not distinguish between royalty and plebeian, politician and pauper, is made clear, as is the fact that both in the courts and in the ghettos a broad range of “therapeutic” interventions were undertaken. Hopkins notes a number of purgatives and ointments that have been used over the centuries in vain attempts to cure smallpox. The use of bloodletting will surprise no one, but one or two other therapies that were tried remind us that much of what passes for science later turns out to be, well, fanciful. Hopkins writes that “the most curious and persistent [therapies] were based on widely held beliefs in the therapeutic efficacy of red objects. The conviction that red substances could help cure smallpox can be traced as far back as tenth-century Japan.”
Hopkins relates the familiar story of Edward Jenner's demonstration, in the late 1790s, that cowpox exposure induced immunity to smallpox. Importantly, however, he also notes that the practice of “inoculating persons with infectious material from mild smallpox cases by blowing dust from powdered scabs up their nostrils ... seems to already have been a popular folk practice among some rural European peasants” as early as the late 1600s. This process of “variolization” was “popularized in England by Lady Montague, wife of the British ambassador to Turkey” in the early 18th century. Thus, Hopkins points out that Jenner did “not so much discover vaccination as ‘introduce it’” when he inoculated a young boy against smallpox with pus taken from the arm of a milkmaid infected with cowpox.
Nevertheless, Hopkins observes, “despite its manifest popularity and rapid spread, vaccination was not embraced without opposition … . Objections were evident from the very beginning of the vaccination era.” He offers two general reasons for this. First, there was significant “scientific scepticism and doubt resulting from the still inadequate understanding of the causative organisms of the disease and their effects on humans.” More interesting is Hopkins' astute discussion of the fact that vaccination “collided with growing sentiments of personal freedom of choice.” Also, foreshadowing many current debates, by the mid-1800s “the fear of smallpox [had] declined after Jenner's discovery, [and] fewer persons took the trouble to be vaccinated or to have their children vaccinated,” which in turn led to several new epidemics.
Hopkins goes on to point out that in late 19th-century Britain, “sustained agitation by the antivaccinationists and the … medical profession's failure to provide leadership” resulted in the collapse of an emerging policy of compulsory vaccination. Plus ça change, plus c'est la même chose: we cannot fail to notice the similarity of these criticisms to those levelled against immunization practices in our own time. This is a huge debate that I cannot do justice to here, but it surely is worth noting that one of the reasons people cite for refusing vaccination is that they simply don't feel that the medical profession, with its indisputable ties to the companies who both produce vaccines and fund the research that assures their safety and efficacy, might not always and everywhere be telling patients the whole story. The details of that story, of course, are in many ways of less significance than the fact that those who report them might be seen as at least somewhat compromised by competing interests.
That Hopkins believes in vaccination goes without saying. But his book is more a story of a horrible disease and its manifestations and implications through the ages than an attempt to weigh in on a current medicopolitical debate. Duly noted is the shameful fact that “some colonists actively and deliberately fostered smallpox's spread among native North Americans in order to break the Indians' [sic] resistance.” Equally sobering is Hopkins' discussion of a laboratory-associated outbreak in London in 1973, and “the world's last cases of smallpox” in 1978, which occurred after Janet Parker, a medical photographer, was infected by virus that escaped from a smallpox laboratory.
If those ignorant of history are doomed to repeat it, it is incumbent on historians to render it with colour, wit and insight — qualities that are somewhat limited here. Compared to newer works, such as Jared Diamond's Guns, Germs, and Steel (1999) or even Edward Hooper's massive tome on HIV, The River (2000), this re-release is dry and monochromatic. This brings me to my largest criticism, which is less of the book than of its publisher, the University of Chicago Press. The merits of relaunching this particular volume (likely at the expense of another) seem questionable, and it bears asking whether it was not just another attempt to cash in on post-9/11 fears.
Ted St. Godard Third-year Medical Student University of Manitoba Winnipeg, Man.
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