SYMHC Classics: Eradication of Smallpox

This 2021 episode covers smallpox, a viral disease that has existed for millennia. But it’s now one of only two diseases that’s been eradicated through human activity, and a global plan was enacted to do it. See omnystudio.com/listener https://omnystudio.com/listener for privacy information.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

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• 0:04Tracy V. Wilson?

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• 0:48Tracy V. Wilson?

  So if you like YouTube, you'll love Premium. Sign up now for your free trial. Terms and conditions apply. Whether you're calling the wise women in your life, video calling your girlfriends across the country, or checking out on someone who always knows how to make you smile, staying connected matters. Those small conversations, shared laughs and quick hellos are what keep relationships strong even when life gets busy. Some of the most life-giving conversations start with just a phone call. That's why AT&T guarantees the network you can rely on, so you can focus on the moments and people that matter most. That's the AT&T Guarantee. AT&T: Connecting Changes Everything. Terms and conditions apply. Visit att.com/guarantee for details. We've all tumbled down an internet rabbit hole trying to self-diagnose, and it leaves

• 1:33Tracy V. Wilson?

  us more anxious than informed. Our feeds are full of wellness trends, but how do we know what's real, what's exaggerated, and what's just wrong? Health vs. Hype from the American Medical Association breaks it all down. Emmy-nominated science communicator Trace Dominguez talks to doctors, influencers, and real people trying these trends, not to cancel them, but to understand them. Because when it comes to your health, who you listen to matters. So listen to Health vs. Hype wherever you get your podcasts. The Old Gays are back with Silver Linings, their lovable podcast from iHeart's Ruby Studio in partnership with ViiV Healthcare. Robert, Mick, Bill, and Jessa strut back down memory lane for season two, sharing lessons on life, love, and loss.

• 2:17Tracy V. Wilson?

  These are the kind of insights that only come from experience. So tune into Silver Linings with The Old Gays on the iHeart Radio app, Apple Podcasts, or wherever you get your podcasts.

• 2:28Speaker 02

  Attention Chicken Nugget fans. Burger King heard that a lot of you didn't like the old Chicken Nuggets, so they got to work and reinvented them. These new Chicken Nuggets are their tastiest, crispiest, juiciest nuggets ever. And because better Chicken Nuggets deserve better sauces, they've reinvented several of their sauces, and they created a brand-new one. The new special savory sauce, which is only available for a limited time at participating US restaurants, don't wait around. You gotta try the new Burger King Chicken Nuggets today.

• 2:57Tracy V. Wilson?

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• 3:35Speaker 03

  Snoring, gasping for air during sleep, daytime sleepiness? I'm Shaquille O'Neal, and this shouldn't be anybody's experience. Ask your doctor about Zepbound Trisepotide, the first and only FDA-approved prescription medicine for moderate to severe obstructive sleep apnea in adults with obesity.

• 3:51Speaker 04

  Zepbound is a prescription medicine used with a reduced-calorie diet and increased physical activity to help adults with moderate to severe obstructive sleep apnea, OSA, and obesity to improve their OSA. Zepbound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15-milligram injection. Zepbound contains trisepotide and should not be used with other trisepotide-containing products or any GLP-1 receptor agonist medicines. It is not known if Zepbound is safe and effective for use in children. Don't share needles or pens, or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zepbound and call your doctor if you have severe stomach pain or a serious allergic reaction.

• 4:36Speaker 04

  Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia, if you're nursing, pregnant, plant-to-be, or taking birth control pills. Taking Zepbound with a sulphonal urea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems.

• 4:58Speaker 03

  Talk to your doctor. Call 1-800-545-5979, or visit zepbound.lily.com.

• 5:07Tracy V. Wilson?

  Happy Saturday. Since we mentioned our episode on the eradication of smallpox this week, we are bringing it out as today's Saturday classic. At the end of this episode, we mentioned Guinea worm disease, also called dracunculiasis, as a disease that could potentially be eradicated. According to the World Health Organization, in 2025, there were 10 reported cases of dracunculiasis. There were 15 in 2024, 14 in 2023, and 13 in 2022. This episode originally came out September 1st, 2021. Enjoy.

• 5:46Tracy V. Wilson?

  Welcome to Stuff You Missed in History Class, a production of iHeart Radio.

• 5:57Tracy V. Wilson?

  Hello and welcome to the podcast. I'm Tracy V. Wilson. And I'm Holly Frey. Late March of last year, I researched and wrote our episode on the eradication of render pests, because in that moment, it just felt really weird to me to work on episodes that were not about the pandemic somehow, because that was dominating everything in our lives. But at the same time, I wanted to work on something that felt kind of optimistic, because the pandemic was dominating our lives. So now it's almost a year and a half later. Here in the US, we had a pretty hopeful springtime regarding the progress of the pandemic.

• 6:39Tracy V. Wilson?

  I know that was not the case in the whole world, but we had what was looking like improved situations. That obviously has taken a turn once again for the worst, or at least the worst, maybe not the worst of ever, but definitely worse. I wanted to kind of return to the idea of wiping a disease off the face of the earth. So render pests and smallpox are the only two diseases that have been eradicated through human activity. Neither one of them is technically extinct, because there are some samples of both viruses that still exist in labs. They're no longer circulating out in the wild, though. And we've talked about smallpox a bit on the show before.

• 7:23Tracy V. Wilson?

  We had our episode on Edward Jenner and the smallpox vaccine, and how the vaccine was developed, and then Jenner's efforts to try to make it more widely available. More recently, we did the episode on the Royal Philanthropic Vaccine Expedition, and that was all about Spain's efforts to transport the smallpox vaccine to the Americas, which required a chain of living human hosts. We mentioned, pretty briefly, the eradication of smallpox in both of those episodes, but we have not gone into detail about how that happened. That's what we're going to talk about today. And when Tracy mentioned it to me, I said, we've covered that. Nope, it just keeps coming up. It just keeps coming up.

• 8:06Tracy V. Wilson?

  We've said in like a sentence how it was done, but it's a more than a sentence worth of explanation. Yeah. Yeah, it's just, it's been just peppered in enough that my brain was like, yeah, that was an episode, right? Nope. So smallpox is a viral disease that has existed for millennia. When it was circulating in the wild, it spread from person to person through the air, usually through face-to-face contact, and it could also be spread through contact with contaminated objects and surfaces. People who contracted smallpox typically developed a high fever and body aches, and that was followed by a distinctive rash. There are two different strains of the variola virus that were causing smallpox,

• 8:50Tracy V. Wilson?

  variola major and variola minor. As that name suggests, variola major caused more serious illnesses, as many as a third of people who were infected with variola major died, as many as 90% of babies died. It was also particularly lethal anytime it was introduced somewhere that it hadn't existed before, such as when Europeans started arriving in the Americas. And in those cases, smallpox usually killed about half the people who contracted it. Among the people who survived the disease, smallpox could also be both disabling and disfiguring.

• 9:27Holly Frey?

  There was and is no cure for smallpox. So even as science and medicine progressed, it continued to be deadly. But it also had some traits that made it a good candidate for a worldwide eradication campaign. Smallpox was easy to recognize and diagnose, unlike, say, the flu, which can resemble a lot of other respiratory infections. Smallpox passed directly from person to person and only infected humans. So there were no hidden reservoirs of the virus that could potentially start a new outbreak. That's different from something like yellow fever, which also infects other primates and is transmitted by mosquitoes. Another plus, once a person had recovered from smallpox, they were immune for life.

• 10:13Tracy V. Wilson?

  For a number of reasons, smallpox outbreaks also tended to develop relatively slowly. Once people were contagious, they were usually also too sick to really leave home. So outbreaks tended to cluster around members of the same household and their immediate neighborhood. And then, once an outbreak was identified, swift action could keep it from spreading very far.

• 10:36Holly Frey?

  And most importantly, there was a way to disrupt transmission of the disease, in this case, a vaccine. In terms of the smallpox vaccine, at first, people prevented smallpox using a technique called variolation that involved intentionally introducing material from one person's smallpox sore or scab into another person. Practitioners in Asia were doing this as early as the 11th century, and the technique spread from there. Then, in the late 18th century, people started to make a connection between smallpox and another much milder disease that was called cowpox. The smallpox and cowpox viruses are both in the genus Orthopox virus, and people who

• 11:18Holly Frey?

  had contracted cowpox seemed immune to smallpox. Several people, including Edward Jenner, tried deliberately exposing people to cowpox as a way to prevent smallpox. Jenner called this "vaccination" after the Latin word for cow.

• 11:33Tracy V. Wilson?

  So both variolation and vaccination could prevent smallpox. But since variolation could also cause full-blown smallpox, vaccination was a lot safer. At the same time, though, vaccination in its earliest forms carried some of the same risks that variolation did, including the potential for transmitting other illnesses like syphilis and hepatitis from person to person during these person-to-person vaccination chains.

• 12:01Holly Frey?

  Sometime in the 19th century, people shifted from using cowpox to using vaccinia virus, which is another orthopox virus, to make smallpox vaccine. The origins of the vaccinia virus are unclear. It is possible that it's actually some kind of hybrid of cowpox and smallpox, or that it developed over time as cowpox virus was passed through multiple hosts in the process of making vaccines. Eventually, vaccinia virus replaced cowpox virus for vaccination purposes, just as vaccination with cowpox had previously replaced variolation with smallpox itself.

• 12:40Tracy V. Wilson?

  At first, vaccines made with vaccinia virus were grown in the skin of live animals like calves, sheep, and rabbits. Eventually, that shifted to growing the virus in tissue cultures or in chicken eggs. These methods replaced those arm-to-arm vaccination chains that we talked about in our episode on the Royal Philanthropic Vaccine Expedition. Countries actually started to outlaw arm-to-arm vaccinations in the late 19th century.

• 13:08Holly Frey?

  Many of the vaccinia strains used to make vaccines were attenuated or weakened by repeatedly passing them through a non-human host, things like chick embryo cells, eggs, or mice. This process resulted in a virus that produced an immune response when a person was vaccinated with it, but couldn't reproduce in that person's body and make them sick. So while vaccination with cowpox virus was safer than variolation with smallpox virus, vaccination with an attenuated version of vaccinia virus was also safer than vaccination with live, unattenuated cowpox.

• 13:44Tracy V. Wilson?

  Yeah, there were still potentials for various complications, but this was an improvement overall. It really didn't take long after the development of vaccines for people to wonder whether vaccines could be used to eliminate smallpox entirely. But early attempts to do this faced a lot of obstacles. As we talked about in our episode on the Royal Philanthropic Vaccine Expedition, early versions of smallpox vaccine lost their potency really quickly, especially in hot weather. And that continued to be true after vaccinia replaced cowpox as the preferred virus for smallpox vaccines.

• 14:22Holly Frey?

  But then, in the 1940s, people started working on dehydrated and freeze-dried versions of the vaccine. The Vaccine Institute in Paris produced a freeze-dried, vacuum-packed vaccine that had a longer shelf life. In the 1950s, Leslie Harold Collier at the Lister Institute studied the preservation methods that were in use and how effective they were. And he developed a process that didn't require refrigeration, even in tropical temperatures. Once the vaccine was reconstituted, it still had a short shelf life. But until that point, it could survive in the field for months. It also protected people from smallpox infection for at least 10 years and offered protection against dying of smallpox for some time after that.

• 15:07Holly Frey?

  Collier's method eventually became the World Health Organization's standard for vaccine used for the eradication campaign.

• 15:14Tracy V. Wilson?

  Smallpox was eliminated in North America in 1952 and in Europe in 1953. And that was done primarily through mass vaccination campaigns, especially ones that were done in response to outbreaks. And this success came in spite of increasing resistance to vaccines and to compulsory vaccine programs. In the United States, this resistance led to a Supreme Court case in 1905. The city of Cambridge, Massachusetts, had been trying to stop a smallpox outbreak and had ordered all adults to be vaccinated or to pay a $5 fine. Henning Jakobsen refused to be vaccinated. And then, after being fined, he took the matter to court.

• 15:57Holly Frey?

  In the words of the court's decision, quote, "The liberty secured by the Constitution of the United States does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. Nor is it an element in such liberty that one person or a minority of persons residing in any community and enjoying the benefits of local government should have power to dominate the majority when supported in their action by the authority of the state." "It is within the police power of a state to enact a compulsory vaccination law, and it is for the legislature and not for the courts to determine in the first instance whether vaccination is or is not the best mode for the prevention of smallpox and the protection of the public health."

• 16:43Tracy V. Wilson?

  We'll get some more on the campaign to eradicate smallpox in the rest of the world after a sponsor break.

• 16:52Speaker 06

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  I love this on plane flights.

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  Ben, how have you been using YouTube Premium?

• 17:56Speaker 06

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• 18:18Tracy V. Wilson?

  Guess who's back in the house? The old gays return for season two of Silver Linings, their hit podcast from iHeart's Ruby Studio in partnership with ViiV Healthcare. Just wait until you hear what hosts Robert McMillan and Jess A. have in store this time around. They strut back down memory lane, navigating life, love, loss, and everything that shaped them along the way. And as usual, someone just might break into song. From leather bars to bathhouses, dance floors to drag brunch, nothing stays off limits. These are the kinds of insights that can only come from experience. So listen to your elders, honey, and discover the silver linings you can take with you. All sass, zero filter, and decades of perspective from four friends proving that queer joy

• 19:03Tracy V. Wilson?

  only gets better with age on the podcast that never gets old. Listen to Silver Linings, available on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 19:17Speaker 06

  First thought is like, wow, how are we going to do all this?

• 19:20Tracy V. Wilson?

  Hey, everybody, it's Tracy from Stuff You Missed in History Class. That's Alan Goya, a planning engineer at AT&T. He's talking about Intuit Dome, home of the Los Angeles Clippers, where every seat, screen, phone, and transaction is connected with AT&T fiber and 5G, defining the fan's experience. And Alan's master plan made it all possible.

• 19:40Speaker 06

  It was going to rival anything that was already built. And that takes quite a bit of people and different teams to all be on the same page.

• 19:48Tracy V. Wilson?

  That includes field services manager Drexel Jones. His team made sure it all came together and held up on game day. Through what Alan's whole crew designed, we connected the event visitors to the world. And after years of hard work and collaboration, it was opening night. To actually see the whole stadium light up and data's flowing is a beautiful. What the fans experience is incredible. It gave me a lot of pride. AT&T, connecting fans to what they love.

• 20:14Holly Frey?

  Connecting changes everything. AT&T.

• 20:17Speaker 06

  Okay, chicken nugget fans, I've got huge news. The new Burger King Chicken Nuggets just dropped and they are the crispiest, the juiciest, and the tastiest chicken nuggets ever at Burger King. Burger King heard that a lot of you didn't like the old chicken nuggets, so they got to work and reinvented them. To go along with the new chicken nuggets, a lot of the sauces were reinvented too, because better chicken nuggets deserve better sauces. We're talking new buffalo sauce, honey mustard, sweet and sour, and even a whole new option too, the new special savory sauce, which is only available for a limited time at participating US restaurants. I mean, you need to taste it all for yourself.

• 21:00Speaker 06

  This new chicken nugget, reinvented, based on real feedback, is made with 100% white meat chicken and is now better than ever. You gotta try the new Burger King Chicken Nuggets and sauces today.

• 21:13Tracy V. Wilson?

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• 21:57Tracy V. Wilson?

  find people who can help drive results. Spend less time searching and more time actually interviewing candidates who check all your boxes. Less stress, less time, more results. Get your $75 sponsored job credit today at indeed.com/podcast. Terms and conditions apply. Hiring now, then this is a job for Indeed Sponsored Jobs.

• 22:24Tracy V. Wilson?

  So you're considering getting a home security system, but you want something that fits your space. Well, with ADT Blue, it's easy to customize a system that's right for you and set it up yourself. Just pick the kit and monitoring plan that makes sense for your home. Let's say you're worried about package theft. The ADT Plus app can walk you through setting up a new doorbell camera kit. Once it's installed, ADT Pros can help you keep tabs on it 24/7, or you can manage it yourself from the ADT Plus app. There are no long-term contracts, so you can change your monitoring plan whenever you want. The flexibility doesn't end there. You can add to your system as you need to with things like extra cameras or motion sensors. Some life decisions are hard, but thanks to ADT Blue, you can DIY trusted ADT home

• 23:09Tracy V. Wilson?

  security in a snap. Head to ADT.com/BLU to build your system today. And to hear more about home protection and other grown-up topics, check out new episodes of Grown Up Stuff on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 23:30Speaker 03

  Snoring, gasping for air during sleep, daytime sleepiness? I'm Shaquille O'Neal, and this shouldn't be anybody's experience. Ask your doctor about Zepbound Trisepotide, the first and only FDA-approved prescription medicine for moderate to severe obstructive sleep apnea in adults with obesity.

• 23:46Speaker 04

  Zepbound is a prescription medicine used with a reduced calorie diet and increased physical activity to help adults with moderate to severe obstructive sleep apnea, OSA, and obesity to improve their OSA. Zepbound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15-milligram injection. Zepbound contains trisepotide and should not be used with other trisepotide-containing products or any GLP-1 receptor agonist medicines. It is not known if Zepbound is safe and effective for use in children. Don't share needles or pens, or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zepbound and call your doctor if you have severe stomach pain or a serious allergic reaction.

• 24:31Speaker 04

  Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia. If you're nursing, pregnant, plant-to-be, or taking birth control pills. Taking Zepbound with a sulphonal urea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems.

• 24:53Speaker 03

  Talk to your doctor. Call 1-800-545-5979, or visit zepbound.lily.com.

• 25:06Tracy V. Wilson?

  The World Health Organization's decision-making body is called the World Health Assembly. And in 1953, the WHO didn't consider smallpox to be a candidate for global eradication. It just wasn't a priority. But five years later, a delegate to the WHO proposed a 10-year eradication plan. That delegate was Professor Viktor Zhdanov, who was Deputy Health Minister of the Soviet Union. And this proposal included vaccine donations that would be provided by the USSR. But even with the promise of donated vaccines, this proposal still didn't pass. At the time, the World Health Organization was working on an anti-malaria program, and that was really just drawing most of the focus.

• 25:51Holly Frey?

  In 1959, the Soviet Union's proposal was reintroduced, and this time it was passed as a voluntary global vaccine campaign. Countries where smallpox was endemic, that is freely circulating, were asked to institute mass vaccine programs with a goal of vaccinating 80% of their populations. And the countries where it wasn't, which were generally richer, were asked to contribute funding or vaccines toward the effort.

• 26:19Tracy V. Wilson?

  At that point, smallpox was being reported in 63 countries, and together, those countries reported 77,555 cases of the disease. But it became obvious really fast that that number was way, way too low. For one thing, those 63 countries only included the ones that were members of the World Health Organization. And some countries where smallpox was endemic were not members at that point, and that included China, which had a population of more than 660 million people.

• 26:51Holly Frey?

  But even in those 63 countries, reporting was all over the place. In countries without a lot of public health infrastructure, smallpox cases weren't really being tracked. But even in places where that wasn't the case, sometimes the only smallpox infections being reported were the ones that ended up in hospitals. In reality, the countries where smallpox was still endemic in 1959 were home to more than half the world's population. And that total number of annual cases was probably more like 50 million, not 77,000.

• 27:24Tracy V. Wilson?

  This voluntary program was focused on national vaccine campaigns. And at least in theory, each nation's campaign would be tailored for its own culture, needs, resources, and infrastructure. But that also meant there was really no central strategy at work. The World Health Organization's role was mostly just making sure that there was enough vaccine available and providing assistance if nations asked for it. It wasn't really coordinating efforts or doing a lot of tracking and monitoring. And because under-reporting of cases continued to be a huge problem, it was almost impossible to tell whether these national programs were even working.

• 28:06Tracy V. Wilson?

  That made it much harder to secure funding or to rally support from nations that had already eradicated smallpox within their own borders.

• 28:14Holly Frey?

  And for the most part, these early national campaigns were not working, at least not very well. In many places, success was measured by how many vaccines were administered. Sometimes this led vaccinators to go after the easiest targets first, like vaccinating all the students at a school. But that meant that children in more outlying areas who were not attending school were not being vaccinated. Since there often weren't clear records, it wasn't unheard of for vaccinators to go back to the same school and vaccinate children again, even though a successful smallpox vaccine typically left a recognizable scar. Because of issues like this, at one point, India was reporting a vaccination rate of

• 28:57Holly Frey?

  140%, because so many people were being vaccinated more than once.

• 29:03Tracy V. Wilson?

  Things moved pretty slowly with all this for about five years. But then in 1964, Dr. Karel Raschka of Czechoslovakia, who was a huge advocate of smallpox eradication, became Director of the Division of Communicable Diseases at the World Health Organization. In 1965, the World Health Organization established a dedicated smallpox eradication unit. And that same year, President Lyndon Johnson announced that the United States would start supporting the global smallpox eradication program. Soon, the US was supporting the work of the Pan American Health Organization in South America, and also funding major vaccine efforts in Western and Central Africa.

• 29:46Holly Frey?

  These years also saw improvements in how smallpox vaccines were administered. Most vaccines that people receive today are administered as shots. They go into the muscle or the subcutaneous skin layer using a needle. But smallpox vaccine goes into the skin's superficial layers. By the mid 1960s, there were a few different methods for doing this. One was to scratch a person's skin with a needle or lancet, and another was to repeatedly press the tip of the needle into a person's skin.

• 30:17Tracy V. Wilson?

  Neither of these methods was very precise. Depending on how skilled the vaccinator was, they might press the needle too far into the skin or not far enough. The amount of vaccine on the needle usually depended on things like how deeply it had been inserted into the vaccine vial. Excess vaccine was often left behind on a person's skin and left to either dry there or be wiped away. Kind of wasteful.

• 30:43Holly Frey?

  It's so fascinating to me to think about this when I think most of the vaccines I've received are like those pre-measured, very carefully, like you open the dose and that's it.

• 30:55Tracy V. Wilson?

  Yeah.

• 30:56Holly Frey?

  So the margin for error of it is a little bit mind-boggling.

• 31:00Tracy V. Wilson?

  Yeah, and there are for sure vaccines that are not administered with shots at this point, but the shots, at least here in the US, are the majority of them.

• 31:09Holly Frey?

  The standard, yeah. Jet injector devices were made to try to address some of this and to make vaccinating more efficient. In theory, these could vaccinate 1,000 people an hour. But in practice, they were limited. Some required electricity to work and others were operated with a foot pedal. That was clunky. So these were only really practical in places where you could bring huge groups of people to one location to be vaccinated. Plus, these devices were expensive and they were hard to clean and they were prone to breaking down.

• 31:42Tracy V. Wilson?

  But then Dr. Benjamin A. Rubin developed the bifurcated needle, which was patented in July of 1965. This was a simple needle and when it was inserted into a vaccine vial, it picked up one measured dose of liquid in between the two prongs. The prongs themselves were designed to keep the needle at the correct angle and depth with a person's skin. And the two-pronged structure meant that it needed fewer presses into the skin to administer each vaccine. This made everything way more efficient. One vial of vaccine could be used to vaccinate four times as many people. And people could be trained to administer the vaccine with the bifurcated needle in

• 32:25Tracy V. Wilson?

  about 15 minutes, even if they had no previous medical experience.

• 32:30Holly Frey?

  Plus, the bifurcated needles were cheap to produce. Although they were originally intended to be disposable, at the World Health Organization's request, they were made from a steel alloy that could hold up to boiling or flaming. They could be sterilized and reused over and over before they started to dull. Boilable containers were designed so that vaccinators could drop used needles into the container as they went and boil the whole thing at the end of a shift.

• 32:57Tracy V. Wilson?

  Also, it was standard practice to clean a person's arm with pads that were soaked in alcohol or soap before giving them the vaccine. I know every time I've gotten a shot, there's been a little alcohol wipe down on the injection site. But studies had suggested that this wasn't actually removing bacteria or other contaminants. It was just sort of moving things around. Studies confirmed that the number of complications and secondary infections after smallpox vaccination was the same, regardless of whether the vaccine site was wiped down beforehand or not. So most vaccination programs, especially in like more impoverished areas,

• 33:40Tracy V. Wilson?

  dropped this step. And together, all of this brought the cost for smallpox vaccination down to about 10 cents a person.

• 33:49Holly Frey?

  By 1966, smallpox was endemic in 31 countries. That was down from the 63 or more reported back in 1959. The number of estimated worldwide cases had dropped from about 50 million to somewhere between 10 and 15 million, although the officially reported tally was still much lower. Somewhere between 1.5 and 2 million people were still dying of smallpox per year.

• 34:14Tracy V. Wilson?

  This was better, obviously, but it was also clear that a voluntary vaccination program wasn't going to be enough to eradicate smallpox. So the World Health Assembly backed a proposal for an intensified smallpox eradication program, which would start on January 1, 1967. Its goal was to eradicate smallpox worldwide within 10 years with the last naturally occurring case being found and isolated by December 31, 1976. The intensified program was given an initial budget of $2.5 million, and this was more money than before. But those 31 countries where smallpox was still endemic also had neighbors

• 34:59Tracy V. Wilson?

  that needed to be protected from introduced cases. So this only worked out to about $50,000 per country.

• 35:07Holly Frey?

  Donald A. Henderson, who was chief of the Centers for Disease Control Smallpox Eradication Program, was made chief medical officer of the intensified eradication program. And in his account, this 10-year goal was pretty arbitrary. It had been inspired by John F. Kennedy's declaration that the US could land a man on the moon within 10 years. He also described the World Health Organization as pessimistic about the chances of success. WHO Director General Dr. Marcalina Candau was from Brazil and thought smallpox eradication would be impossible just in the Amazon basin, much less anywhere else. According to Henderson, the World Health Organization wanted an American to head the program so that if it failed, the US would shoulder some

• 35:52Holly Frey?

  of the blame, rather than all of it falling on the WHO.

• 35:56Tracy V. Wilson?

  I read a write-up that Henderson wrote briefly about this, this campaign. And he had sort of spelled out how it sort of seemed like things were happening almost on a whim. And he was like, I'm just, I'm writing this to disabuse you of the notion that there may have been extensive planning involved in the outset of this. We will get to how this intensified program, even though it still seemed a little haphazard, how it successfully eradicated smallpox after another quick sponsor break.

• 36:32Tracy V. Wilson?

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• 37:41Holly Frey?

  Guess who's back in the house? The old gays return for season two of Silver Linings, their hit podcast from iHeart's Ruby Studio in partnership with ViiV Healthcare. Just wait until you hear what hosts Robert McMillan and Jessa have in store this time around. They strut back down memory lane, navigating life, love, loss, and everything that shaped them along the way. And as usual, someone just might break into song. From leather bars to bathhouses, dance floors to drag brunch, nothing stays off limits. These are the kinds of insights that can only come from experience. So listen to your elders, honey, and discover the silver linings you can take with you. All sass, zero filter, and decades of perspective from four friends proving that queer

• 38:26Holly Frey?

  joy only gets better with age on the podcast that never gets old. Listen to Silver Linings, available on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

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• 39:36Holly Frey?

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• 40:46Speaker 03

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• 41:02Speaker 04

  Zepbound is a prescription medicine used with a reduced-calorie diet and increased physical activity to help adults with moderate to severe obstructive sleep apnea, OSA, and obesity to improve their OSA. Zepbound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15-milligram injection. Zepbound contains trisepotide and should not be used with other trisepotide-containing products or any GLP-1 receptor agonist medicines. It is not known if Zepbound is safe and effective for use in children. Don't share needles or pens, or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zepbound and call your doctor if you have severe stomach pain or a serious allergic reaction.

• 41:47Speaker 04

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• 42:17Holly Frey?

  We've all done it, tumble down an internet rabbit hole trying to self-diagnose. And sometimes doing our own research can leave us more anxious than informed. Your feed is packed with wellness trends telling you to cold plunge, protein max, detox, track your sleep. But what's actually real? What's exaggerated? What's just wrong? That's exactly what Health vs. Hype from the American Medical Association and iHeartMedia's Ruby Studio is here to find out. Each episode, Emmy-nominated science communicator Trace Dominguez, who's racked up billions of views across PBS, Discovery Channel, and YouTube, talks to doctors, influencers, and real people trying these trends. Not to cancel them, not to hype them more,

• 43:02Holly Frey?

  but to actually understand them. Because when it comes to your health, who you listen to matters. Start asking better questions and listen to Health vs. Hype on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 43:19Speaker 06

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• 44:30Tracy V. Wilson?

  When the World Health Organization established the Intensified Smallpox Eradication Program, smallpox was still endemic in multiple countries in Asia, South America, and Sub-Saharan Africa. And especially at first, a lot of the financial support and a lot of the vaccines for the program were coming from wealthier nations where smallpox had already been eradicated, nations like the United States. And for these countries, their motive was not just humanitarian. There was also a lot of money and politics involved. For example, if smallpox was eradicated worldwide, these nations would not need to fund vaccination programs in other countries

• 45:12Tracy V. Wilson?

  or spend money vaccinating their own populations anymore. For wealthier countries, these smallpox vaccination programs also served as opportunities to vaccinate people for other diseases and to try to build political influence and goodwill in the places where the programs were operating.

• 45:31Holly Frey?

  Also, countries where smallpox had been eradicated still occasionally faced outbreaks that were usually introduced through travel. Although these tended to be very small and quickly contained, they were still disruptive and expensive, and sometimes sparked a public panic. Global smallpox eradication would mean not having to deal with any of that anymore.

• 45:53Tracy V. Wilson?

  Yeah, there was a lot of self-interest involved in the wealthier nations who gave money and vaccine and other support to this whole program. Although each nation still needed a plan that was customized to its own needs, there also needed to be a better unifying strategy behind this whole program, something beyond a target of vaccinating 80% of the population. That number, I feel like, keeps getting repeated today as like the standard for what is needed, but it had not really been based on epidemiology or on public health data. It just seemed like a reasonable operational goal for the voluntary program. And it had also become clear that the number of vaccines administered

• 46:38Tracy V. Wilson?

  did not really work as the goal, since teams might wind up vaccinating the same people more than once, driving up their vaccination numbers without actually vaccinating more of the population.

• 46:51Holly Frey?

  One big gap that needed to be filled with this was surveillance. Reporting methods were still all over the place, and eradication was only possible if health officials actually knew when and where outbreaks were happening. This was something that just required a ton of communication from the World Health Organization, and all through every level of a nation's governments, all the way down to individual doctors, hospitals, and community leaders who needed to report any suspected cases in order for this to work.

• 47:22Tracy V. Wilson?

  Another gap was standards for the vaccine itself. The Soviet Union and the United States were the two biggest donors of vaccines, with the USSR donating 140 million doses a year, and the United States donating 40 million doses. Other countries donated as well, but in smaller amounts. In 1967, the World Health Organization asked vaccine manufacturers to submit samples of their smallpox vaccine, and only 30% of them met WHO standards for quality and potency. Some of the submitted vaccine samples did not contain any vaccinia virus at all. Others were contaminated with bacteria.

• 48:06Tracy V. Wilson?

  This led to the WHO establishing more stringent standards for the vaccines, and then monitoring them to make sure the vaccines actually met those standards.

• 48:16Holly Frey?

  As all of this was happening, of course, wars and other unrest were making vaccination programs difficult in some places where smallpox was still circulating. The Nigerian civil war began in 1967, which made things more dangerous for health workers and their patients, and it also led to a vaccine shortage. But this shortage also led to a shift in how smallpox vaccinations were prioritized. Since there wasn't enough vaccine available for the whole population, health officials focused on vaccinating family members and other close contacts of anyone who developed smallpox. This turned out to be an effective way to stop the spread of the disease, and Nigeria's last smallpox case was reported in May of 1970.

• 48:59Tracy V. Wilson?

  The focus on monitoring and reporting cases that was so necessary for the program's success also made it easier to see trends in how and where smallpox outbreaks developed. Vaccinators started taking better advantage of seasonal variations. They would use all that surveillance work to trace people's contacts and to vaccinate more people at the start of the season, when the smallpox case numbers were lower, to contain those outbreaks before they spread.

• 49:29Holly Frey?

  By 1973, smallpox existed in only five countries: Bangladesh, India, Nepal, Pakistan, and Ethiopia. Bangladesh had previously been free of the disease, but it had been reintroduced there as refugees fled the Indo-Pakistani war. And by this point, about 80% of the vaccines being used for this effort were being made in the countries where they were being administered. And at least 95% of the vaccines that the World Health Organization tested met its standards.

• 49:58Tracy V. Wilson?

  Having only five countries remaining was obviously a huge accomplishment. But at the same time, more than 700 million people lived in Bangladesh, India, Pakistan, and Nepal. They were all neighboring countries, and it had become really obvious that a mass vaccination program just wasn't going to be able to eradicate the disease in this region. These neighboring nations had been trying to vaccinate their whole populations for years. There were 120,000 health staff working on the program in India alone.

• 50:34Holly Frey?

  So the strategy shifted to mirror what had actually worked in Nigeria in the late 1960s. Health officials quarantined anyone who contracted smallpox and used extensive contact tracing to determine who else might have been exposed. They vaccinated their immediate families and the surrounding communities. This became known as the ring method, basically making a ring of vaccinated people around each active smallpox case so that the disease just could not spread.

• 51:04Tracy V. Wilson?

  Monitoring and surveillance were critically important to this process since health workers could only make a vaccinated ring around cases of smallpox that they knew about. So health workers traveled from place to place, educating local doctors, healers, leaders, and officials about smallpox reporting, and seeking out and isolating active smallpox cases, and then vaccinating anyone who may have come into contact with these patients. Using this method, Pakistan saw its last reported case of smallpox in October of 1974, Nepal in April of 1975, India in May of 1975, and Bangladesh in October of 1975.

• 51:47Holly Frey?

  Unfortunately, although Ethiopia's last case of smallpox was reported in August of 1976, by that point, it had been reintroduced into neighboring Somalia, which was still experiencing active cases. In 1977, Donald Henderson resigned as the head of the Intensified Eradication Program. He was replaced by Asao Arita, who had been medical officer of Infectious Disease Control in the Ministry of Health and Welfare in Japan before joining the World Health Organization.

• 52:19Tracy V. Wilson?

  That same year, 1977, authorities started trying to contain an outbreak of varicola minor among nomadic peoples in the desert region that spans parts of Ethiopia, Somalia, and Kenya. Smallpox was reintroduced into Kenya, but that introduction was quickly contained. And Kenya reported its last case in February of 1977. In July of 1977, Somalia and Ethiopia went to war over control of part of this region, and then that hampered efforts to control this ongoing outbreak in Somalia. Somalia actually reported 300 cases of smallpox in 1977.

• 53:00Holly Frey?

  The last one was the case of Ali Ma'ou Malin, who was a cook at Merka Hospital. On October 12, 1977, a driver carrying two smallpox patients to an isolation camp stopped at the hospital to ask for directions. Malin got into the car and rode with them for 15 minutes or less. He did that so he could guide them to where the leader of the smallpox surveillance team lived. These two patients were siblings, six and one and a half years old, and when authorities traced their contacts, Malin was overlooked. Although Malin worked in a hospital, he wasn't vaccinated against smallpox. In an interview later in his life, he said that he had been afraid of the vaccine.

• 53:41Tracy V. Wilson?

  There are a couple of accounts that said that he had been vaccinated, but his vaccine hadn't taken, and that disagrees with the interview that he gave later. He started feeling sick on October 22, 1977, and at first, doctors thought he had malaria. Then he developed a rash on October 26, and he was initially diagnosed with chickenpox. He started to worry that he had smallpox on October 29, and on October 30, somebody reported to health officials that he had a potential smallpox case. His diagnosis was confirmed through lab tests that day.

• 54:16Holly Frey?

  The effort to prevent Malin's smallpox case from sparking another outbreak really demonstrates what was involved in all of this. Contact tracing identified 161 possible exposures, some of them as far as 120 kilometers away. This included hospital staff, family, and friends, many of whom had visited him while he was ill. Authorities identified 33 face-to-face contacts who had no evidence of prior smallpox infection and had not been vaccinated within the past three years, and 12 of those had no prior evidence of a smallpox infection or vaccine at all.

• 54:55Tracy V. Wilson?

  All those people were vaccinated, along with all known and possible contacts and their families. During an 18-day surveillance period, health workers made multiple in-person visits to each person who had potentially been exposed. The number and frequency of those visits depended on the person's relative level of exposure and their risk. So if they had been around him a long time and were not vaccinated, they got multiple different visits from the health staff, but if they had been vaccinated and it was a shorter time, they might get two check-ins. In the end, though, none of those 161 contacts developed smallpox.

• 55:34Holly Frey?

  But it did not stop with those 161 contacts. Warning signs were posted at Merka Hospital, which was placed under 24-hour guard. Vaccines were administered to everyone who worked at the hospital and all of the patients. Patients in the surgical ward were quarantined until November 13, and in the medical ward, they were quarantined until November 17. The hospital also suspended all non-emergency care, referred outpatient procedures to other facilities, and required daily temperature checks for patients and staff.

• 56:07Tracy V. Wilson?

  There was also a mass vaccination campaign in the ward of the city where Malin lived and the hospital was. This was a multi-phase process, with vaccinators going house to house to vaccinate everyone and to look for any signs of smallpox cases, and then returning to vaccinate anybody who had arrived since the last pass or whose first vaccines showed no evidence of a vaccine scar. Once that ward of the city was done, health workers did the same for the rest of the city. Checkpoints were established at all the roads and footpaths leading into Merka, and anyone who was coming or going was advised of this possible outbreak. They vaccinated everybody who was passing through, and then on top of all of that, there

• 56:52Tracy V. Wilson?

  was a massive public information campaign with a reward for reporting smallpox cases.

• 56:58Holly Frey?

  In the end, Ali Ma'ou Malin was the last person to contract naturally occurring smallpox. That was 10 years, nine months, and 26 days after the start of the Intensified Eradication Campaign. So it just barely missed that 10-year goal, even if it had been arbitrary.

• 57:15Tracy V. Wilson?

  After recovering from smallpox, Malin later became part of the effort to eradicate polio, working as a vaccinator and organizing door-to-door campaigns. He would share his own story about how he had been afraid to be vaccinated for smallpox and then had ultimately become the last smallpox patient. Somalia was declared free of polio in 2007, but it reemerged there in 2013. When that happened, Malin went back to his vaccinating work. He suddenly became ill not long afterward, and he died on July 22, 2013, of what was diagnosed as malaria.

• 57:53Holly Frey?

  But the last person to die of smallpox contracted it after Malin did. That was Janet Parker, a medical photographer who was infected on the job at England's Birmingham University Medical School in 1978. The microbiology lab was one floor below her darkroom in the office that she used to make phone calls. It is not clear exactly how she came into contact with smallpox virus from the lab. At the time, the prevailing theory was that it was through a shared air vent, but later studies suggested that that was actually unlikely.

• 58:27Tracy V. Wilson?

  Parker had been vaccinated for smallpox, but as we mentioned earlier, the vaccine's protection was expected to last for about 10 years, and she had been vaccinated back in 1966. The strain she was exposed to was also a particularly deadly one. Her mother, Hilda Whitcomb, contracted smallpox while caring for her, but she recovered. But Janet's father, Frederick, died of an apparent heart attack while in quarantine. Hilda missed both his and Janet's funerals because of her own illness. Health workers quarantined hundreds of people who had possibly been exposed, and at least 500 people were vaccinated to keep this outbreak from spreading any further.

• 59:11Holly Frey?

  This lab had been scheduled to close as the World Health Organization tried to reduce the number of facilities that had samples of the virus. Although the lab had previously been inspected and was allowed to continue operation, it didn't have a lot of basic safety measures in place to contain deadly pathogens, things like changing facilities, dedicated showers, and airlocks. It also had been the source of another smallpox case, also involving a medical photographer, back in 1966.

• 59:41Tracy V. Wilson?

  It really seems like when they inspected the lab and they were like, "It doesn't have all these things that we recommend to control potential spread of pathogens, but like, only three people work here, so it's probably fine." This became a huge scandal later. The lab's director, Dr. Henry Bedson, had been trying to finish as much of his work as possible before the lab was closed. He blamed himself for Parker's illness and took his own life a few days before her death, which was on September 11th, 1978.

• 1:00:13Holly Frey?

  As this was happening, health officials were still closely monitoring other countries to confirm that smallpox was no longer circulating there. On October 26, 1979, a ceremony was held in Nairobi to announce that smallpox had been eradicated in the Horn of Africa. That was two years after Ali Ma'Al Malin had first developed a smallpox rash. On December 9, 1979, the Global Commission for the Certification of Smallpox Eradication declared smallpox eradicated. And on May 8, 1980, the World Health Organization confirmed the disease's eradication.

• 1:00:50Tracy V. Wilson?

  There's been some stuff floating around social media lately about how this was only possible because everyone did their part, either implying or just flat out saying that everybody accepted the vaccine during this process. But that is just not true. There was a lot of resistance and hesitancy, especially in campaigns to vaccinate children. A lot of parents just didn't want to do something that might hurt their child or make them sick. The process of administering the vaccine also evolved over the years, and some parents that had, like, pretty traumatic vaccine experiences that they didn't want repeated with their child. Anti-vaccine activists such as Lilly Lote, who worked for the National Anti-Vaccination

• 1:01:33Tracy V. Wilson?

  League and edited its journal, distributed literature against vaccines in general and against the smallpox vaccine specifically, well into this eradication effort.

• 1:01:45Holly Frey?

  Aside from that, because earlier versions of the smallpox vaccine were grown in the skin of live animals, animal rights activists and anti-vivisectionists objected to their use. When methods progressed to using tissue cultures, mistrust of science led people to object to this method as well.

• 1:02:03Tracy V. Wilson?

  In places like India, smallpox vaccination had been a routine part of the public health service since 1947, and yet there were still outbreaks for decades after that. This led people to claim that the vaccine was worthless, or even that it was what had been causing the smallpox. Nations stopped vaccinating people for smallpox once the disease had been eradicated from within their borders, and in some people, this just reinforced that perception. Like, there were no vaccines happening anymore. That must be why there's no smallpox happening anymore.

• 1:02:37Holly Frey?

  There were also religious objections to smallpox vaccinations. Various peoples and cultures interpreted smallpox as coming from divine will, or interpreted existing methods of smallpox prevention or treatment as religiously significant. And most of the last nations to eradicate smallpox were the same ones that had a long history of being colonized and exploited by European powers. So people were understandably suspicious of this largely Western-led public health effort. So the global eradication of smallpox happened in spite of hesitancy and resistance, not in the absence of it.

• 1:03:15Tracy V. Wilson?

  So that is how smallpox was finally eradicated. It does still exist in a couple of labs. There have been ongoing conversations about destroying those remaining stocks, and it keeps getting postponed. I would really like it if we, as a global society, could get control of the COVID-19 pandemic, because unless the Carter Center program successfully eradicates Guinea worm disease in the immediate future, we don't have any more eradications of diseases to cover on this show when I need an optimistic story related to all this.

• 1:03:54Holly Frey?

  Right. Where, uh, that would be great to report as a history in the making, but fingers crossed.

• 1:04:08Tracy V. Wilson?

  Thanks so much for joining us on this Saturday. If you'd like to send us a note, our email address is [email protected]. And you can subscribe to the show on the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.

• 1:04:30Holly Frey?

  A rare disease diagnosis can change your life, but it doesn't have to define your future. In season seven of Untold Stories: Life with a Severe Autoimmune Condition, host Martine Hackett continues the conversation with people living with MG, CIDP, and the broader rare disease community, exploring what comes after diagnosis through stories of hope, progress, and connection. Produced by Ruby Studio in partnership with Argenx, listen on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 1:05:01Tracy V. Wilson?

  You ever show up late to the game and your friends already saved your seat, your drink, even a plate? That's looking out. That's having your back. And that's exactly what AT&T does with the AT&T Guarantee. They know staying connected matters, so they actually guarantee a network that comes through when it counts. AT&T has connectivity you can depend on, or they'll proactively make it right, just like that friend who takes care of things before you even ask. AT&T: Connecting Changes Everything. Terms and conditions apply. Visit att.com/guarantee for details.

• 1:05:34Speaker 03

  Snoring, gasping for air during sleep, daytime sleepiness? I'm Shaquille O'Neal, and this shouldn't be anybody's experience. Ask your doctor about Zepbound Trisepotide, the first and only FDA-approved prescription medicine for moderate to severe obstructive sleep apnea in adults with obesity.

• 1:05:50Speaker 04

  Zepbound is a prescription medicine used with a reduced calorie diet and increased physical activity to help adults with moderate to severe obstructive sleep apnea, OSA, and obesity to improve their OSA. Zepbound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15-milligram injection. Zepbound contains trisepotide and should not be used with other trisepotide-containing products or any GLP-1 receptor agonist medicines. It is not known if Zepbound is safe and effective for use in children. Don't share needles or pens, or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop Zepbound and call your doctor if you have severe stomach pain or a serious allergic

• 1:06:35Speaker 04

  reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia, if you're nursing, pregnant, plant-to-be, or taking birth control pills. Taking Zepbound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems.

• 1:06:57Speaker 03

  Talk to your doctor. Call 1-800-545-5979, or visit zepbound.lilly.com.

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