28 February 2021

As the world moves toward mass vaccination against SARS-CoV-2 in 2021, many unanswered questions remain. Will vaccine administration be mandatory? Will proof of vaccination be required to attend gatherings such as sporting or entertainment events? Will the unvaccinated be allowed to travel? Will life insurance be more costly if an individual refuses the COVID-19 vaccine? And so many more.

In my previous editorial I talked about my postvaccination DNA being altered and making friends with my injected microchip. This tongue-in-cheek discussion of some of the conspiracy theories regarding vaccination against the coronavirus downplays the real fear some individuals have about being immunized. Many think the vaccine was rushed into production and is not safe. Significant numbers of vaccine refusals are likely as people worry about potential adverse health outcomes. Conspiracy theorists have had a field day, and some are staunchly against vaccination as they falsely claim the vaccine was made from aborted fetal tissue. I have even heard of some groups fearing the vaccine will mark you with the sign of the beast (devil), which is based on a biblical chapter in Revelation. These fears, which seem ridiculous to most, are very real to some.

One night, while thinking about all of this, I was unconsciously rubbing my left deltoid when my fingers rubbed against my smallpox scar. Until 1970, babies were routinely immunized against smallpox, leaving us oldies with a mark either on the outside or inside of our upper arms. I wonder if some lessons about mass vaccination might be found in the history of this other terrible virus.

It is estimated that roughly 300 million people died from smallpox in the 20th century. Its case fatality rate was estimated at around 30%. Contrast that to the COVID-19 mortality rate of around 2% with a current death toll of 2.5 million.

In 1796, British physician Edward Jenner noted that milkmaids who had contracted the milder bovine variant (cowpox) did not become ill with smallpox. He grabbed his gardener’s 8-year-old son and scratched his upper arm with the contents of a cowpox blister from a milkmaid. A few months later he repeatedly scratched the boy’s arm with contents from smallpox blisters and the boy never contracted the disease. As an aside, I do not think this study would receive ethics approval in 2021. Regardless, this groundbreaking work (which was initially rejected by the Royal Society of Physicians) led to the development of a vaccine.

Opposition to smallpox vaccination existed almost as soon as the vaccine was developed. Rationale for this criticism varied and included sanitary, religious, scientific, and political reasons. Some objectors and clergy thought the vaccine was un-Christian because it came from an animal. Some distrusted medicine in general and thought that smallpox was not an infection but that it came from decaying matter in the atmosphere. Some individuals were against vaccination because they thought it violated their personal liberty. Many governments started mandatory smallpox vaccination programs, which just added to the tension.

In Leicester, England, three individuals were jailed for refusing to be vaccinated and this same town had a demonstration march in 1885 with up to 100 000 individuals protesting mandatory vaccination.

Regardless, as the 20th century progressed, a general acceptance of vaccination against smallpox took hold. In North America, the smallpox immunization program was stopped around 1970 as the final recorded case on the continent occurred in 1949. The last known naturally acquired case of smallpox on the planet occurred in 1977 in Somalia. The last death from smallpox occurred in 1978, when a medical photographer working above a research lab in England contracted the disease. Currently, smallpox can be found only in the CDC lab in Atlanta and the State Research Lab in Russia.

I would like to believe that we have learned our historical lesson and that COVID-19 vaccination will go smoothly with general acceptance and wide public uptake, but sadly, history does tend to repeat itself. On that point, let us remember what happened to smallpox—it was eradicated largely due to widespread distribution and uptake of the vaccine. Is it too early to dream of the same outcome for SARS-CoV-2?
—David R. Richardson, MD