Joaquin Duarte thought his 1939 battle with smallpox--the sweats, the delirium and the scarring sores--was among the scourge's last gasps in this country.
Six decades later, he is sweating over the possibility that terrorists will bring it back.
"It's pretty bad," said Duarte, 81, recalling the days he lay inside his "covered wagon," a tent of blankets, struggling not to scratch the pus-filled pox. "I wouldn't want anybody to go through it. It's an awful thing to go through."
Health officials are worried, too, that one of the greatest triumphs of public health--the eradication of this terrible virus--could be in peril. So much so that they are ordering 300 million doses of vaccine, enough for every American, in case smallpox reemerges.
Federal health officials have also begun inoculating doctors, lab workers and other experts against smallpox, and training them to identify and contain possible outbreaks.
As survivors and medical veterans of the last smallpox war well know, there are good reasons for hope and fear.
Sixty or 70 years ago, public health officials were able to quickly respond to outbreaks and vaccinate enough people to prevent mass infections. But survivors in this country, such as Duarte, had a relatively mild form of smallpox, which kills 1% of those it infects.
Experts believe that the type of smallpox used in a bioterrorist attack would be much more virulent, killing 30% or more.
In any case, smallpox is highly contagious, making it an even more frightening prospect than anthrax, a noncontagious disease that in the past month has severely shaken the nation.
The chances of smallpox being used as a biological weapon remain small, experts say--but with anthrax now being sent through the mail, no one is feeling complacent.
Smallpox survivors and their caretakers can take pride, and even offer some lessons, in defeating a deadly disease. But they shudder at the thought of seeing it emerge again, perhaps more powerful and widely spread than before.
"I just imagine, if it starts spreading, how it [could] stop a country," said James Orr, 53, the last smallpox victim in North America.
Long before there was any such concept as terrorism, smallpox was sowing terror.
American colonists were so fearful of the scourge that many forbade their children to travel overseas--even to attend England's most prestigious colleges--lest they be infected. "The smallpox was always present, filling the churchyard with corpses, tormenting with constant fears all whom it had not yet stricken," British historian Thomas Babington Macaulay wrote in his 1848 "History of England."
The disease, which has been traced to the time of the ancient Egyptians, claimed hundreds of millions of lives over the centuries. In the United States by the 1930s--more than 130 years after a vaccine was developed--the number of annual reported cases ranged from 5,000 to 15,000.
If history is any guide, the panic surrounding the disease can be even more contagious than the virus. Until its eradication in the United States in 1949 and in North America in 1962, even an isolated case could produce near-hysteria.
Officials scurried to vaccinate people wherever smallpox surfaced. In 1947, after a businessman returning by bus from Mexico to New York City infected four people before dying, New York officials vaccinated 6 million people in a month. Only 12 people became sick and two died--but the city, in a dramatic overreaction, virtually exhausted its vaccine supply, said Jonathan Tucker, author of "Scourge: The Once and Future Threat of Smallpox."
Fear was the public's gut response once more in 1962, when Orr fell ill.
The 14-year-old son of missionaries, he was on his way back from Brazil, on a New York-to-Toronto train, when a rash broke out on his body.
"I saw the pox and I thought, 'I wonder what this is?' "
When word got out that it was smallpox, "People [in New York] just started to panic," he said. All it took was "just that one case."
U.S. officials were so alarmed that they considered sealing the country's border with Canada and vaccinating millions of Americans.
That step was averted when Dr. Donald A. Henderson, a federal disease control official who later led the World Health Organization's smallpox eradication effort, urged a more measured response. He suggested treating the case as though it had emerged on American soil, in effect treating Canada as the 51st state.
The government settled on vaccinating the 3,000 or so people who had walked through Grand Central Station the same day Orr passed through, as well as fumigating the planes and trains that he took from Brazil to Toronto.
Orr's proved to be the last case of smallpox on the continent.
Henderson, 73, chosen last week by the Bush administration as a top bioterrorism official, employed a strategy of rapid containment--building a firewall around victims by vaccinating everyone with whom they had had contact.
It was an important step. "The fact that we were able to stop smallpox by identifying cases and vaccinating contacts clearly opened the way to a different strategy than panicked mass vaccination," said Dr. Stanley Foster, a former federal health official who headed the eradication effort in Bangladesh.
Painful Disease Is Highly Contagious
Even without terrorists' tinkering, smallpox is a fearsome foe. It is painful, disfiguring, essentially untreatable--and easily spread.
"My body was like one big scab, you understand?," said Duarte, who caught the disease in 1939 from a sick friend in Portugal. He was admitted to a New York hospital after sailing home.
"The smallpox, those pox, are close together. When they started drying up, my body was . . . real itchy. The nurse always told me I shouldn't pick on it with my hands because it would leave big scars if I touched it."
The retired rubber factory worker, who lives in South Bend, Ind., still bears scars on his forehead.
The disease left emotional scars, too. It was devastating to families.
San Antonio resident Charles Barber, 69, will never forget the suffering of his mother, father and brother, all of whom contracted smallpox in the last U.S. outbreak in 1949, in Texas' lower Rio Grande Valley. His mother died of smallpox and other complications; the others survived.
Of his father, he said: "There was not a place on his body, including the palms of his hands and the bottom of his feet, where there wasn't a scab."
Barber was the only one able to care for his parents. His father was "out of his head with fever" when his mother died, he said.
The intense physical discomfort wrought by the disease was made worse by patients' sense of isolation. No one could touch them.
"I remember my family would come visit and they would be on the other side of the glass window," said Atherton, Calif., resident Fred Kamphoefner, 80, who was fresh out of high school in San Francisco when he was infected in 1939. "They were just very cautious."
Barber, who was 17 when the pox struck his family, remembers that he and everyone else were quarantined for eight weeks in their home. The phone company passed a telephone through a window to help them communicate with the outside world, and the Red Cross dropped by a box of sheets and towels. Otherwise, they were shut off.
Henderson said officials learned from experience how contagious smallpox could be. For every person infected, they were likely to infect at least an additional 10. It had to be contained within a few weeks or the numbers would grow exponentially.
Smallpox symptoms, including high fever, fatigue, and severe headaches and backaches, appear about 12 to 14 days after exposure. A rash develops on the face, arms and legs, then quickly spreads to the rest of the body, where it is sometimes mistaken for measles or chickenpox. The flat red lesions become pus-filled and begin to crust. The scabs fall off in three to four weeks--if a patient survives.
The virus is not contagious before symptoms appear. But once pox develop in the mouth, the disease can be spread by coughing, shedding scabs or talking to anyone within a few feet. To infect someone, it takes a very small amount of virus, transmitted through the air or through contaminated clothing and bed linens.
Those who were smallpox victims, or helped care for them, learned to respect its terrible power. Survivors have immunity to the disease and can't get it again. But some of them and their family members have a sense of foreboding about the suffering it would bring to others, if unleased by terrorists in even more virulent form.
"I think something very catastrophic is going to happen, and I don't think we're going to be able to stop it," Barber said.
Fears of a More Potent Virus
For all the lessons learned from the smallpox war, many experts say the country is less prepared today to fight the disease than it was 60 years ago.
In part that is because terrorists' version of smallpox could be far more deadly and widely disseminated. One possibility, experts say, is that terrorists would spread the virus with a specialized sprayer generating an extremely fine mist. The virus could remain suspended in the air for several hours and be inhaled by many people.
Another reason for worry is that much of the U.S. population has never been vaccinated, and for many of those who have been, the protection has worn off. The United States stopped vaccinating against smallpox in 1972, after 23 years had passed without any reported infection within the country.
Elizabeth Fenn, whose book "Pox Americana" was published last month, said Americans are as susceptible today to smallpox as Native Americans were when European settlers arrived.
"Today, we're all Indians," she said. "Smallpox is a disease with long legs."
The anthrax scares of the past month provide some dress rehearsal: The two diseases are deadly and durable in the environment, and they are difficult to detect until symptoms appear.
But in smallpox, unlike anthrax, the victims are made into weapons, multiplying opportunities for the virus to spread.
The government apparently has a contingency plan of mass vaccination--but as yet it has 15.4 million doses of vaccine on hand. And mass vaccination carries its own risks: A portion of the population would suffer side-effects or even contract a related virus from the live vaccine, which is grown in calves.
Henderson, a hero of the last smallpox war, is among the worried well-informed. He says he's not sure whether the United States could respond adequately if smallpox reemerged.
The public health system was better in the 1930s and '40s than it is now, he said. "We've done very little with infectious disease now for a long time. We don't have very much competence in this area."
Compounding the problem are advances in transportation that allow easy movement throughout the country and across the globe.
"Surveillance and containment might work in an African village where people don't move very much, but it would be much more difficult in a modern American city," Tucker said.
At this point, Henderson and others say the risk of a smallpox outbreak remains slim. The only known supplies of the virus are kept in heavily guarded refrigerators at the Centers for Disease Control and Prevention in Atlanta and at the Russian Vector lab in Siberia.
Still Iraq and North Korea are believed to hold covert supplies. And survivors of the last smallpox war wonder: Did they outlast a scourge only to see something far worse inflicted on their children? "There's great concern for this [next] generation," said Orr, who is a missionary in Brazil. "I really don't know what to expect ahead."
Times staff researcher John Jackson contributed to this report.Copyright © 2015, Los Angeles Times