5(c) Clear proof that isolation was the remedy

There are a number of proofs (apart from Haygarth’s experiment and Leicester) that it was isolation, not ring vaccination, that eradicated smallpox. First, we know from the experience of the hospital in Meschede that vaccinating contacts after failure of isolation, i.e. after they have been exposed, can’t stop smallpox. More importantly, in his 2011 book, “House on Fire”, William Foege wrote about an instance in India where they had to deal with “almost ten thousand new cases in only two states” but “the program did not have enough containment teams to travel to every new outbreak, even if they did no vaccinations … The central smallpox team decided to put at least a cursory effort into containment” – i.e. they focused on mainly on isolation. But he wrote: “we were saved by an unexpected finding: even poor containment teams were able to slow smallpox transmission.” In other words, even when ring vaccination was not implemented, isolation stopped smallpox in its tracks. 

While the SEP did consume a large number of vaccines, it was large-scale surveillance, contact tracing and isolation that rid the world of smallpox. The outcome would have been the same without the vaccine.

6. The magnitude of the challenge: India’s case

In his Preface to the WHO 1979’s book, Donald Henderson wrote: “To me, the eradication of smallpox from India represents one of the most brilliant achievements in the annals of the global eradication programme, if not in the history of public health itself”. He noted that 150,000 workers participated in the program in India, of which 250 were from abroad. We get an idea of the number of cases isolated successfully from Henderson’s 2013 book, “Smallpox: The Death of a Disease” where he wrote that “in Bihar state two-third of the over 188,000 cases that occurred in the country in 1974, were found and contained. … In May 1974 in a single week, search teams recorded 8,600 pending outbreaks with over 11,000 new cases in Bihar state alone.” 

7. It was failed isolation led to the last smallpox case

The SEP holds enormous lessons for effective isolation of diseases like smallpox, Ebola and SARS. Even a small gap in isolation can spread disease. Ali Maow Maalin in Somalia was the last case of natural smallpox on Earth. He caught smallpox while riding a short distance to an isolation camp with two children who had smallpox. Isolation cannot be allowed to break even during a journey to the isolation camp. In due course, Maalin was properly isolated and smallpox got eradicated. Designing good isolation is a challenge but is doable with care.

8. The law of isolation

After examining hundreds of books and papers on a range of diseases, I have arrived at the following law of isolation. IF viral excretion occurs after symptoms AND the sick person is immobile AND the virus is mainly transmitted at close distance by droplets and/or bodily fluids AND the disease is easy to diagnose, THEN isolation may be suited to the disease. 

Smallpox is the only disease that ticks all these boxes. Even SARS and Ebola, which have been effectively dealt with through isolation, fail in one regard: ease of diagnosis. Nevertheless, since they do not transmit before symptoms, patients with SARS and Ebola can typically be identified and isolated before the disease spreads.

Many other factors need to be considered in determining the nature of isolation. Smallpox and Ebola viruses are physically among the largest, which makes them suitable for control with N95 masks and personal protective equipment (PPE). Further, diseases like SARS and Ebola need hospitalisation because patients tend to deteriorate without multi-disciplinary care. Hospitalisation does make them harder to isolate. Fortunately, since most smallpox patients do not require intensive care, they were able to be isolated at home, thus also reducing transmission during the trip to hospital. Human factors also play a crucial role in the success of isolation. 

9. If isolation is so difficult, how can quarantine be easy?

Early isolation efforts (mainly for the plague but also for yellow fever and cholera) were fundamentally flawed. Isolation can’t stop rats that scurry across houses, or mosquitoes, or bacteria that transmit via the water. But the idea of isolation, and by implication quarantine (lockdown) for an infectious disease like covid is also ludricous. Covid transmits asymptomatically and patients are typically mobile while they are infected. In addition, it is not a trivial exercise to diagnose covid. PCR tests can’t meaningfully exclude infected staff at aged care centres (a method suggested by the focused protection proposal of the Great Barrington Declaration). Let’s assume that I’m a staff member who has caught covid. At the beginning of my shift I test negative since the virus in my lungs has not yet multiplied. During the shift, however, the virus multiplies and I become infectious even as I display no symptoms of the disease. Quarantine will obviously fail in such a case. As I have showed earlier, quarantine is a fool’s errand and must be abolished. 

Conclusion

It was stringent isolation at home – with sick patients surrounded 24/7 by multiple guards – that broke the back of smallpox. The vaccine was used but the same benefit could have been obtained by deploying smallpox survivors or staff equipped with PPE. Had the vaccine never been invented, therefore, smallpox would have been eradicated by now – possibly much sooner since doctors would have spent more time in studying the science of isolation. 

Readers interested in details about this topic can refer to the public heath textbook that I’m currently writing, a draft of which is available online. 

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