A [monkey]pox o’ your throat, you bawling, blasphemous, incharitable dog!

Reflections on Monkeypox and Smallpox but not Chickenpox

It may not seem fair, after all we’ve been through, to be confronted by yet another virus. But at least admit one small consolation: what could be a better name than monkeypox?

Patients have been asking, so here are the basics. Monkeypox starts off a lot like Influenza, or Covid for that matter: fever, headache, muscle aches, chills and fatigue. Characteristic signs include prominent lymphadenopathy, or swollen glands in the neck, and, of course, the rash, otherwise known as the pox.

Monkeypox virus belongs to the Orthopoxvirus genus, same as smallpox, vaccinia, cowpox, and myriad other poxviruses named after camels, horses, racoons, and skunks, all causing similar-looking skin eruptions.

In the case of monkeypox, the rash appears a few days after the fever. Lesions develop into firm, raised blisters, filled with clear fluid that turns into pus. Unlike chickenpox, where the lesions appear at different stages of development, monkeypox lesions transition through their various phases all at the same time.

The number of lesions can range from a few to several thousand. They tend to be concentrated on the face, palms and soles, but can appear all over the body, including on the mouth, genitals and eyes. Over several weeks they crust, dry up, and fall off, sometimes leaving scars.

Sounds dreadful, but here’s the good news: monkeypox is uncommon, difficult to transmit, and rarely deadly. I have never seen a case of it in my life, nor (as yet) heard of anyone who has. It is typically found in the developing world, where it carries a mortality rate of 3-6%. In developed countries, that rate drops to less than 1%. And even with the current spread outside of its endemic area, there are only 25 known cases of monkeypox in the entire U.S.

Monkeypox is spread by close personal contact – including skin-to-skin or saliva exchange. Famous last words, you say, recalling the early days of Covid – what if it mutates?

Luckily, that’s unlikely to happen. While Covid is a small RNA virus, unstable and prone to mutations, the Orthopoxviruses are DNA viruses, larger and more stable. In fact, the genomic stability of smallpox is one reason why it became the first infectious disease to be successfully eradicated worldwide: it never developed the ability to evade the vaccine.

So at the risk of having to eat my words, I will say that monkeypox does not keep me up at night. Thanks to monkeypox, however, I have found myself thinking a lot about smallpox.

For those interested in the history of medicine, smallpox provides a dramatic example of both the best and the worst of human beings; a vehicle for one of our greatest crimes as well as one of our biggest victories.

Smallpox is an ancient disease. We have evidence of it from Egyptian mummies more than 3,000 years old, but it probably emerged in humans as far back as 10,000 B.C. And once it emerged it stayed, causing epidemic waves of death and suffering on every continent to which it was introduced.

Horribly disfiguring, smallpox killed more than a third of its victims. The numbers are staggering. In the ancient world, entire populations were wiped out by smallpox plagues, and the devastation it wreaked played a role in the decline of the Roman Empire. In the 20th century alone, more than half a billion people died from smallpox.

Worst of all, though, is what happened in the Americas. It is thought that smallpox was brought to Mexico in 1520, carried by an infected African slave on a Spanish boat sailing from Cuba. By that time, thanks to centuries of exposure, Eurasian populations had built up a significant resistance to smallpox – a herd immunity, if you will.

Not so for the Native Americans, who were immunologically naive.

Smallpox tore through the American continent like a hail of neutron bombs, decimating empires and softening the ground for the hostile forces of conquistadors and colonialists. By some estimates, smallpox (along with measles and influenza), wiped out 95% of the indigenous population.

I have heard various theories over the years to explain the success of European colonialist adventures, ranging from culture, to weaponry, to climate. Nonsense. It was smallpox.

It’s one thing for European invaders to claim victory over the full force of the Incan and Aztec empires. It’s quite another, and a lot less impressive, when the only ones left to resist are a few desultory survivors of a massive but incidental smallpox pandemic.

Notably, I first learned about this history as an adult, at a performance by John Leguizamo called Latin History for Morons (highly recommend, you can find clips on YouTube). Meanwhile, even as a child I was familiar with the story of smallpox-infected blankets given to the Indians by the Colonists. Turns out, while the former is true, the latter may have never happened (or if it did it probably didn’t work – blankets are not a great way to transmit smallpox).

Maybe that’s just an example of how everyone loves a good conspiracy theory. Or maybe it’s just that humans have a need for the illusion of control. Better to believe that calamities are the result of human intent – even evil intent – than the result of unintended consequences beyond our power to plan or prevent.

In any case, so much for the crime (do I hear objections that it was perhaps not a crime if there was no intent? Alright then, call it an accomplice to the crime). What was the victory?

Why, the eradication of smallpox, of course.

For centuries it was known that variolation – exposing oneself to a small amount of smallpox pus by scratching it into the skin or inhaling it through the nose – could cause a milder case of the disease that would confer immunity. Still, like Russian roulette, this was a dangerous game to play and many died in the process.

Fast forward to 1796, when an English doctor named Edward Jenner, observed that milkmaids who developed cowpox often became immune to smallpox. Jenner knew about variolation, put two and two together, and came up with the idea for vaccination.

To test his theory, he took some pus from a milkmaid’s cowpox sore and injected it into the arm of James Phipps, his gardener’s nine-year old son. He then exposed the child to smallpox and sure enough, young Phipps turned out to be immune (I know, nice move Ed – how about next time you experiment on your own kid!).

In 1801, Jenner published “On the Origin of Vaccine Inoculation” and the rest is history. At some point in the 1800’s the virus used to manufacture the vaccine changed from cowpox to vaccinia, which is still used today.

By 1952, smallpox was eliminated in North America. By 1953, it was eliminated in Europe. In 1957, the World Health Organization announced the goal of eradicating smallpox worldwide. In 1978, after many frustrations, challenges and setbacks, the last person to contract smallpox, a Somali cook named Ali Maow Maali, made a full recovery and smallpox was finally vanquished.

The eradication of smallpox is arguably the greatest achievement in the history of global public health. Number of deaths prevented so far, based on extrapolated historical data? Over 200 million and counting.

Contemplating the highs and lows of smallpox is enough to make one’s head spin: to paraphrase Shakespeare, ‘What a piece of work is smallpox.” Perhaps more to the point, and to quote him directly, “What a piece of work is man.”

Thanks to genetic overlap, the smallpox vaccine doubles as the monkeypox vaccine. It is not currently available commercially but the government has a stockpile for use in the event of biological warfare.

As I write this on Friday late afternoon, a CDC advisory hits my inbox: 2022 Health Advisory #11: Monkeypox Detection and Transmission in NYC. Bottom line, 10 more cases.

Hmm. Maybe I’ll turn in early and get some extra rest. While I stand by my words to lose no sleep over monkeypox, I can’t claim to know how long that will last.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
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