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Last Updated

03 Feb 2003

Source: Minneapolis Star Tribune, February 3, 2003

Doctors who treated smallpox not alarmist about disease threat

Jill Burcum, Star Tribune

Dr. John Kersey, now head of the University of Minnesota's Cancer Center, was making hospital rounds as a young Army doctor in Karachi, Pakistan, in 1966 when he saw them.

Two men and a woman with smallpox, their facial features nearly blotted out by large pustules, their lungs struggling for breath.

Kersey can still instantly summon the moment. "It's a horrible, horrible disease. I don't want anyone to ever have it again," he said.

Yet as the nation prepares to defend against smallpox as a weapon of terror, Kersey and two other Minnesota doctors who once treated the deadly disease say their concerns about the risks to Americans today aren't keeping them awake at night.

Kersey, university colleague Dr. Ashley Haase and Dr. David Williams of the Mayo Clinic are part of an elite medical group: the 200 to 400 U.S. doctors who have seen smallpox victims. Their expertise has largely been overlooked during federal bioterrorism planning.

All three say they are reassured by planning done during the past year to prepare the nation to deal with a bioterrorism attack. Their experience also suggests that smallpox is readily recognized and that it typically doesn't spread beyond bedside contacts of victims -- even in the medical conditions of war-torn Pakistan in the 1960s, where all three saw the disease.

And they know the vaccine works. All three were immunized. None became infected, even after touching smallpox victims. For all these reasons, they believe the disease probably would be brought under control quickly in the United States, but they emphasize that the medical system must prepare for an outbreak.

"Now that I work in cancer, I see hundreds of thousands of people dying of this," Kersey said. "I can't imagine that happening with smallpox."

These doctors' observations come at a time when some hospitals and health care workers have questioned the need for a national vaccination program.

The issue also was debated in last week's New England Journal of Medicine, in which one editorial called for vaccinating 15,000 health care workers instead of 2.5 million as the Bush administration plans. The editorial's author, Dr. Thomas Mack, a Carleton College alumnus and University of Southern California medical school professor, also studied smallpox in Pakistan from 1965 to 1968.

"This is not something we need to be terribly afraid of, but something we need to be prepared for," said Mack, who met Williams in Pakistan but didn't know Kersey or Haase.

Mack said he is not especially concerned that vaccine-resistant smallpox strains might have been engineered as weapons. He said such strains, if they exist, would spread in the ways he witnessed in Pakistan and could be contained.

But he said public health authorities haven't asked him to assist in smallpox defense planning. All three Minnesota doctors also said they have not yet been asked to help.

Kersey, Haase and Williams have spent much of their careers in areas of medicine unrelated to smallpox, and they said they will leave decisions on vaccine strategy to public health experts.

Memories revived

None of the three Minnesota doctors knew one another in 1960s Pakistan. Now they're surprised to find themselves digging up distant memories.

"If you'd have told me back then that I'd be sitting here in 2003 talking about smallpox, I wouldn't have believed you," said Haase, an internationally known AIDS researcher and head of the Microbiology Department at the University of Minnesota.

Haase, 63, was a senior medical school student in 1965 when an international study program sent him to Lahore, Pakistan, to test a new drug to treat smallpox.

He had never seen smallpox before he arrived. In Pakistan he sought out victims, driving around the countryside in a jeep with a Pakistani military translator.

When the two men arrived in one of the dusty villages dotting the Himalayan foothills of northern Pakistan, they would ask for the village chief. Then they would share tea, as custom dictated, and ask if any villagers had smallpox.

If the answer was yes, Haase would ask to see the smallpox victims. Most often, they were cared for by family members in dark, cramped, homes.

Haase didn't need much light to make a diagnosis. The pustules are distinctive, usually appearing on the face, legs and arms. After observing one or two cases, "I could see from 200 feet away whether someone had been a victim or not," Haase said.

Sometimes, he would encounter smallpox victims along the road. One woman was journeying to a distant part of Pakistan to visit relatives. She had the disease's pustules but felt strong enough to make the trip.

The woman, and others like her, probably helped keep smallpox circulating in Pakistan, Haase said. The virus can be shed in pustule scabs. Still, cases were rare, indicating that the disease did not spread easily without prolonged, close contact, he said.

That was good, because the drug Haase tested didn't work. It often made people vomit. Some patients' families got angry and forced him to leave villages in a hurry.

Williams, 70, a retired lung specialist at the Mayo Clinic, was a Methodist medical missionary stationed in Pakistan from 1965 until late 1973. He still remembers his first smallpox case at the United Christian Hospital in Lahore.

The man, who lived in the countryside, arrived covered with pustules. The diagnosis was obvious.

Williams and the other doctors sent the man elsewhere for treatment after a day or so.

No one else at the hospital contracted the disease, including the men in the open ward where the man stayed, he said. Although most staff members were vaccinated, many patients were not.

Williams believes the man survived. The two other smallpox patients he saw probably weren't as fortunate. Williams once traveled to Afghanistan to help deliver supplies to a small hospital. In the hospital's courtyard were two women with smallpox. The hospital staff kept them outside to prevent the disease from spreading, he said.

With the advanced medical care available in the United States, Williams said he believes any cases here would be recognized as quickly as they were in Pakistan. The smallpox survival rate might be higher now because of better medical care, he said. It is fatal about 30 percent of the time.

"In that country and at that state of health care, we were able to contain and eradicate smallpox; we ought to be able to reproduce at least that much in the United States," Williams said.

Kersey, 64, had much the same experience at a hospital in Karachi, in southern Pakistan.

That's where he saw the three smallpox patients whose pustule-marked faces still are imprinted on his memory. Yet no one else in the hospital became infected; most staff members were vaccinated.

In the slums of Karachi, where he volunteered to care for patients, it was different. The crowded conditions, malnutrition and other health problems helped the disease spread.

"These were extraordinarily poor health conditions," he said. And smallpox wasn't the only threat. Far more common, Kersey said, were leprosy, malaria, rabies and deaths from a disease that still kills millions of people -- diarrhea.

That's a point to consider, he said, as the nation prepares for bioterrorism.

"This is important, but you need to put it in perspective in terms of all the health problems," he said. "We need to be concerned about anthrax and smallpox, yes, but we can't forget about cancer, heart disease, suicides or alcohol-related traffic deaths either."