Facts I Learned From Angel of Death: The Story of Smallpox

Old king plague is dead! The smallpox plague is dead!

Ramses V, one of the first known people to die of smallpox, died in 1157 B.C. However, in general, smallpox seems to have become firmly established throughout Eurasia over the course of the first millennium A.D. Smallpox is weirdly absent from Greek and Roman medical texts, and referred to only ambiguously in the Bible. The first Chinese reports date back to 250 B.C.; the first Indian reports of smallpox date back to sometime before 400 A.D.

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In 1241, the first smallpox outbreak in Iceland killed 40% of the population.

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In 1541, one smallpox-infected slave of the conquistadors caused an epidemic that killed 20 million people and led to the fall of the Aztec empire.

A Spanish monk:

They died in heaps, like bedbugs … As it was impossible to bury the great numbers of dead, they pulled down the houses over them in order to choke the stench that rose from the dead bodies, so that their homes became their tomb.

Pizarro could conquer the Incan Empire because smallpox had already killed a huge percentage of the population. In Brazil, mass baptisms led to mass deaths from smallpox. In 1616, smallpox killed 90% of the Algonquins and Narrangassetts; between 1636 and 1650 it drove the Hurons extinct. White people rejoiced at the justice of God, Who sent plagues to kill the pagans and bring His people land.

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A quote from the late nineteenth century travelogue, An Australian in China:

Infanticide is hardly known in that section of Yunnan of which Tali is considered the capital. Small-pox kills the children. There is no need for a mother to sacrifice her superfluous children, for she has none.

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Smallpox could be so disfiguring that siblings could see each other daily for a week before recognizing each other.

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In the 18th century, a third of all cases of blindness were caused by smallpox.

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Pockmarks were a job requirement for household servants and nursemaids in the 17th century, as they meant you had already had smallpox.

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Early modern cures for smallpox:

A fine example was the Hippocratic notion, later embroidered by Rhazes, that fever was caused by an excess of blood, the ‘heating humour’. This could be relieved by making the patient sweat, which also dragged the contagion of smallpox to the skin where it could be safely expelled. So the fire was stoked up, the windows and doors shut and the victim tightly wrapped in blankets – even if this tore open the fragile pustules. Some experts insisted that the bedding must not be changed until recovery; it must have been an additional bonus to be released from a stinking cocoon that was stiff with a three-week concretion of pus and tissue fluid. If sweating was inadequate, it could be forced with various herbs and toxic metal salts…

The colour red was also claimed to assist healing: red bedclothes and bedding warmed the skin, drawing out both sweat and contagion.

Red could also be applied by having patients drink pomegranate juice or by painting pustules with carmine. Other “treatments” included bleeding, starvation, denying the patient liquids, and forcing the patients to drink beer mixed with sulphuric acid. In 1719, two doctors dueled over whether it was better to use laxatives or emetics to treat smallpox.

As you might expect, poor people were more likely than rich people to survive smallpox because they had a lower risk of encountering doctors.

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The first Chinese records of variolation¹ are from 1550, using the odd method of blowing smallpox scabs up the nostrils. The Chinese knew to select mild cases as donors and to use dry scabs rather than fresh. However, they also believed it was necessary to use a silver blowpipe and to pick the nostril by gender (right for boys, left for girls).

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Throughout the eighteenth century, the Royal Society of London got a lot of letters like "by the way, people in this country are also doing this weird variolation thing.” (It was practiced in China, Africa, the Middle East, and some parts of Europe.) Finally, in 1714, the Royal Society published its first report about variolation. No one appeared to care. In part this was because the Royal Society's journal was full of crap:

a dubious recipe that claimed to cure distemper in cattle, North American Indian herbal cures for gout, dropsy (fluid accumulation) and scrofula (tuberculosis of the lymph glands) – and the suggestion, made in all seriousness, that birds migrating from New England took shelter on a moon that had somehow managed to avoid detection.

Also variolation seemed miraculous. It always worked? It guaranteed a mild case? Medicine just didn't do that.

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Smallpox variolation was popularized in America by Cotton Mather, whose other exploits included inflaming the Salem Witch Trials, sending the moon bird migration thing to the Royal Society, and convincing people to convert their slaves to Christianity:

Mather tailored his strategy for bringing the Bible to the slaves according to the learner’s perceived intellectual capability – “the greater their Stupidity, the greater must be our Application” – and he produced a simplified catechism for “Negroes of a limited capacity.”

Mather was the first person to report mastodon bones to a scientific journal, though someone else discovered them. He characterized them as proof of a race of giants before the flood. He also reported that the mastodon's femur was twice as long as it actually was. Minor errors.

Although he was pro-variolation, Mather was less tough on smallpox than one might hope: he rejoiced that smallpox had killed off the Native Americans "Nine parts of Ten (yea ’tis Nineteen of Twenty) among them; so that the Woods were almost clear of these pernicious creatures to make Room for a better Growth."

Variolation was very controversial. Against Mather’s writings, one variolation skeptic “pointed out that this was the man who believed that pigeons migrated to an invisible moon.” The doctor who variolated patients in Boston was nearly lynched. A vaccine skeptic threw a grenade through Mather's window, although they messed it up and it didn't explode, and anyway they attached a note explaining that Mather was a "Dog.” Unclear on whether this person knew how grenades work.

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In principle, variolation could be done by anyone, without medical training. Indeed, in many cultures variolation was performed by elderly wise women. Afraid of losing their profits from smallpox treatments, doctors came up with numerous solutions to make smallpox variolation more dramtic: bleeding, emetics, even caustic medicine to create blisters when they were too slow in coming naturally. Doctors used deep incisions instead of a simple scratch. While people were less likely to die if the smallpox germ was applied through a scratch (because it transmitted less of the smallpox germ), your grandma couldn’t make a cut this deep, could she? You need a professional for that!

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The Suttons were a family of variolators known for a mortality rate of only 1 in 8,000 because of their secret strategies to make variolation safer and more effective. A family member eventually revealed that the secret was “a shallow scratch, careful selection of only mildly-affected donors and no bleeding – just a gentle laxative and sometimes a secret powder, later shown by its side-effects to contain mercury and antimony.” And they were doing so well until the mercury, too.

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Anti-variolation sentiment was far more reasonable than I’d expected. Variolation ensured a mild case of smallpox. People rarely self-isolated, and sometimes went so far as hosting parties to celebrate their protection from smallpox—while their infection was ongoing. And certainly wealthy sick people saw no reason to send away their servants. In short, variolation regularly sparked smallpox outbreaks.

And because only rich people could afford to be variolated, variolation protected the wealthy while spreading disease among the lower classes. Although variolation protected the variolated from smallpox, it’s unclear whether variolation actually reduced deaths from smallpox overall.

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But not all anti-variolation sentiment was this sane:

Set around the unfortunate Job and entitled The Dangerous and Sinful Practice of Inoculation, this railed against this “diabolical operation” which “promotes the increase of vice and immorality”. Strong stuff, especially as Massey intended ‘diabolical’ to be taken literally. It was the Devil who had smitten Job with boils; this affliction was obviously smallpox and therefore the Devil had been the first to give the disease deliberately, that is, to inoculate. Alternative diagnoses were ignored, as was the later use of the same trick by Moses. Massey further argued that smallpox was sent by God to punish mankind for sin, to test his people’s faith and to frighten them away from vice: “If men were more healthy, ‘tis a great chance they would be less righteous.” Therefore, only the Atheist, Scoffer, Heathen and Unbeliever could dare to interfere with the Almighty’s wish to hit His targets. To summarise: “Let them Inoculate and be Inoculated, whose Hope is only in and for this Life!”

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In 1746, the Smallpox Hospital in London opened to provide free variolation for the poor. It was founded by, obviously, the Quakers.

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When a doctor introduced variolation to Russia, the Empress arranged for a “chain of getaway horses… to enable him to escape from Russia if he killed anyone important.”

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The adoption of variolation in France led to a new hairstyle, the pouf à l’inoculation. People could also get the fashionable spotted bonnet à l’inoculation.

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Edward Jenner was traumatized by his experience of variolation, which seems to have given him PTSD.

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The first confirmed vaccination was in 1774, when a gentleman farmer named Benjamin Jesty performed the variolation procedure on his wife and his sons using a blister on a cow's udder. Unfortunately, his wife's arm got infected and she nearly lost it.

Word spread rapidly, not of Jesty’s innovative and courageous experiment, but of his cruel abuse of his wife and children, poisoning them with bestial filth from a sore on a cow’s udder. Jesty was pelted with abuse and sometimes stones whenever he ventured out to market.

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Edward Jenner’s mentor was a doctor named John Hunter. Hunter inoculated himself with gonorrhea pus to see if he would contract gonorrhea. He contracted not only gonorrhea but also the patient’s syphilis. Hunter’s other adventures included falsely claiming to be able to freeze people and resurrect them (a few centuries too early for cryonics, alas). When he died, his colleague surgeons voted on whether to send condolences to his widow; the majority were against.

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In addition to vaccination, Jenner discovered that cuckoo birds murder their adoptive siblings. Jenner also proposed (but did not publish) that migrating birds flew south in the winter instead of burying themselves in mud or water. Or going to an invisible moon.

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The Royal Jennerian Society celebrated Jenner’s birthday every year with a dinner so luxurious that Jenner didn’t want to attend. It folded because they chose a secretary who, among other things, had a habit of threatening women and children with scalpels.

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A statue of Jenner was put up in Trafalgar Square. After four years, the anti-vaxxers got it removed to an obscure part of Kensington Garden. Now there's just an empty plinth in Trafalgar Square.

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Pasteur proposed that all vaccinations be called "vaccinations" in honor of Jenner, even if no cow was involved.

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‘Vaccinia’ (used in smallpox vaccines) actually isn't cowpox—it's a form of horsepox. This is probably because Jenner thought cowpox and horsepox were the same thing and horsepox managed to reach fixation. Horsepox is presently extinct in horses, but continues to affect rats.

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The recipients of Pearson’s lymph in spring 1799 included the equally energetic Jean de Carro, a Geneva physician working in Vienna. De Carro immediately began vaccinating there and also sent lymph to Thomas Bruce, Earl of Elgin, who had not yet begun plundering marble friezes from the Parthenon and was British Ambassador in Constantinople… Bruce promptly vaccinated his son and spread the word – not just in Turkey but also to India. 8 The lymph that Bruce sent to India survived the long trip (which had earlier defeated attempts by Jenner to introduce vaccination to that country) and was used to vaccinate a girl in Bombay in 1802. This single case began a chain-reaction of arm-to-arm vaccination which ultimately spread across India.

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Brahmins refused the cowpox vaccination because it was blasphemy, since the vaccination came from a cow. So a British person made a fake book claiming that historical Brahmins vaccinated with cowpox. The Brahmins accepted it. No problem that can’t be solved with a bit of antiquities forgery.

Many other Indians refused vaccination on the grounds that it left a scar which British people might use to identify them for some inscrutable British plot. Shades of Bill Gates’s microchips.

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Carlos IV, King of Spain, had perhaps the most dramatic vaccination project. His brother and sister-in-law had both died of smallpox, leaving him with a hatred of the disease. Carlos IV ordered that cowpox be carried across the Atlantic Ocean via 22 boys. Every ten days, two boys were vaccinated using lymph from the preceding boys.

The [smallpox vaccination] Expedition lasted almost three years, circumnavigated the world and covered a total distance of nearly 50,000 miles. 22 It first sailed to the Canaries, then to Puerto Rico and Caracas in Venezuela, where the Expedition divided into two. Between them, these forces retraced the routes of the original Conquistadores. De Balmis followed Cortéz’s trail to Mexico, crossing to the Pacific coast where an updated brief from the King told him to continue sailing west to the Philippines and then to the Spanish outposts in China at Canton (Guangzhou) and Macau... Meanwhile, Salvany’s half of the Expedition had followed in Pizarro’s footsteps, heading south through Colombia, down the coast of Peru to Argentina and Tierra del Fuego, then home across the Atlantic.

At each stop, they set up vaccine centers that would provide arm-to-arm vaccination (and in one case deliberately infected the cows with cowpox).

De Balmis and Salvany created a sensation almost everywhere they went, with emotional welcomes for the heroes and especially the young boys who had risked their lives by sailing halfway around the world to bring salvation.

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The first person to be vaccinated in Russia, an orphaned girl, received a lifelong pension and the name Vaccinoff.

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A handful of assorted anti-vax theories:

The reader may remember [a prominent anti-vaxxer] as the proponent of anal leech therapy in smallpox. His other therapeutic coups for treating the disease included emptying the bowel with emetics in children or drastic purgatives in adults (presumably with reapplication of any leeches unfortunate enough to be dislodged by the diarrhoea). He also revived a recipe from over a century earlier, namely lemonade fortified with sulphuric acid. If this all sounds passive, it was in line with his own philosophy about the nature of the disease. Smallpox, he said, was caused by “sharp moral shocks" such as fear and anger, as he sought to prove with a series of “likely cases” of “spontaneous” smallpox which he published in 1884.

Noting that “fear and panic drive the general public to seek protection in a poisoned lancet”, he offered a safe alternative, already proven effective in plague, cholera, etc.: common salt. Statistics were not needed to prove that it worked, although he used mathematics to show that smallpox outbreaks correlated with sunspots and the Northern Lights. Smallpox was due to “adverse meteorological influences ... the presence or absence of ozone, or the electrical activity of the air we breathe”.

Noting that humans need 21 years to reach maturity, whereas cows only take five years, he concluded that a cow’s cells must grow much faster than a human’s. Therefore, he declared, introducing a cow’s protoplasm into a human “must upset the constitutional balance and promote the general condition in which cancer finds birth.”

Dr. W. A. Farr, who proposed that the fatal infectious (zymotic) diseases operated to a quota. When deaths from one infection declined for whatever reason, others compensated by killing more people.

Chiropractic held that smallpox was the same as chickenpox, and both were caused by inflamed nerves that "expressed too much heat at their twig ends." Smallpox was easily fixable via back massage.

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Alfred Russel Wallace and George Bernard Shaw were both anti-vaxxers. Alfred Russel Wallace held that vaccination killed 52 children a year (false), which was more than died of smallpox (false) and that vaccination had never prevented a death from smallpox (false).

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Pro-vaccination women set out to provide public health education of… varying… usefulness:

• Hygiene, covering drains, first aid, drinking clean water: Good!

• Don't live in cellars or overcrowded housing: Great. Very helpful. Who is going to pay the rent on a more expensive place?

• Keeping your husband faithful and out of pubs by being a good cook and wearing unfussy clothes in flattering colors: …

the ability of the demon drink to pickle its victims was demonstrated by a blood clot (kindly lent by the Medical School) perfectly preserved in a glass jar full of alcohol.

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A 1906 pamphlet by Lora Little was so popular that anecdotes and arguments from it were used as late as 1957.

[Lora C. Little] locked horns with sugar, millionaires, white flour, germ theory, high heels and enemas and, as Vice-President of the Anti-Sterilization League in Portland, led the fight against the compulsory castration of male “habitual criminals, moral degenerates and sexual perverts”.

Between Little and Mather, Angels of Death is full of people who combined being fantastically ahead of their time with… not… that.

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The phrase "conscientious objection" emerged in the 1900s (decade) to refer to parents who didn't want their children vaccinated.

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The anti-vax movement was given ammunition by pro-vax doctors’ persistent habit of Lying.

For example, pro-vaxxers claimed that protection from vaccination lasted forever, which gave anti-vaxxers ammunition because… it obviously didn’t. So every time the protection wore off and a vaccinated person died of smallpox, the anti-vaxxers scored a victory. Pro-vax doctors only admitted that vaccination’s protection faded over time in the 1860s.

Pro-vax doctors falsely claimed that arm-to-arm vaccination could never spread syphilis. 500 doctors signed an open letter saying it couldn't, nine years after the first confirmed case of vaccination-transmitted syphilis.

Cory was at least brave enough to put his beliefs to the test and… deliberately inoculated himself with lymph from several syphilitic children. This grand geste turned into a tragic grande folie. Cory nearly died of acute syphilis and was left partially paralysed.

The lymph used in vaccination of this time was wildly varying in quality. Many people used horsepox and "grease" instead of cowpox. No one washed their hands. Arm-to-arm vaccination transmitted any bloodborne disease the donor had, not just smallpox. The process of producing lymph was extremely unsanitary. Inspection under a microscope revealed that most cow-derived lymph was contaminated with manure, straw, and bacteria. Vaccinators would gladly vaccinate sick children with contagious illnesses and then fail to sterilize the instruments. Indeed, vaccination instruments were almost never sterilized, as long as they looked visibly clean.

Poor hygiene led to several common complications of vaccination. For example, improper sterile technique led to erysipelas, which is caused by streptococci bacteria. It caused 20-40 deaths per year in England. Improper sterile technique also caused ulcers at the injection site, which sometimes required amputation.

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Even today, the only treatment for smallpox is IV fluids, ventilation, and hope.

That didn’t stop people from coming up with other ideas. For example, Nobel laureate Niels Ryberg Finsen:

Finsen decided that there must be substance to the oddly tenacious notion of ‘red treatment’ and experimented with shining red light on smallpox patients. 30 He claimed that this ‘erythrotherapy’ prevented pustules and therefore scarring. The effect was weak, however, and could be wiped out by even brief exposure to sunlight. Patients therefore lived in a dim red twilight, with heavy curtains nailed over the windows; sometimes the entire sick-room was painted deep red for maximum effect.

Other suggested treatments included:

the mind-boggling and possibly brain-frying “diathermy to the pineal gland” to keep life-preserving energy circulating in the seat of the soul, and cryptic nutritional advice delivered by telegram: ESSENTIAL KEEP ALL SMALLPOX CONTACTS ON STRICT VEGETARIAN DIET + WILL WRITE

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Destroying the last vials of smallpox could be a violation of international environmental law, which forbids deliberately driving species extinct.

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In 1793, John Haygarth was the first recorded person to think of smallpox eradication, although admittedly only on the country level. In 1801, Jenner proposed eradicating smallpox via vaccination, only a few years after his discovery of vaccination.

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In 1895, Sweden became the first country to eradicate smallpox.

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Smallpox eradication was easier in North America because Variola minor—a significantly milder and less fatal form of smallpox—gradually displaced Variola major. It’s free variolation!

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Smallpox eradication was suggested in 1953 but went nowhere. Professor Viktor Zhdanov, the Russian deputy minister of health, suggested it again in 1958, and it took.

Unfortunately, Viktor Zhdanov is #problematic:

Viktor Zhdanov, the energetic Health Minister who had brought the notion of global smallpox eradication to the WHO in 1958, was later appointed to head up Russia’s network of germ-warfare facilities, known as Biopreparat.

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The WHO agreed to do the project. But smallpox eradication was underfunded because no one saw it as a priority:

The Director-General of the World Health Organisation (WHO) during the crucial marshalling phase of the eradication programme repeatedly voiced his conviction that smallpox could never be wiped out, while one of his aides promised to eat a tyre if it was.

Smallpox eradication happened because of D. A. Henderson, one of the greatest heroes of the 20th century.

D. A. Henderson was a doctor at the CDC's Epidemic Intelligence Service who was monomaniacally obsessed with smallpox. He attached a smallpox eradication program to an attempt by the U.S. government to eradicate measles from various West African countries. This got him noticed by the Director-General of the WHO. The Director-General appointed Henderson head of the new Smallpox Eradication Unit, apparently on the logic that Henderson would fail and then no one would try to eradicate smallpox anymore.

The campaign began in 1966 in Brazil and Indonesia. It started with a team of five: three doctors and two secretaries. At its largest, the team was ten people.

Henderson soon realized that only about 1% of smallpox cases were reported. Instead of about 100,000 cases worldwide each year, there were 15 to 20 million. Data on mass vaccination campaigns had been faked, in some cases claiming that as much as 120% of the population had been vaccinated. In some regions, 30-40% of vaccinations failed (didn't leave the characteristic scar) because of poor technique or low-quality vaccines.

Brazil’s home-produced vaccine was unreliable, especially in the heat, but national pride blocked all attempts to bring in the more stable freeze-dried preparation. Declaring large numbers of smallpox cases was seen as an admission of defeat which some countries could not face, even if they had allowed their national vaccination programme to wither away. Some officials in Bangladesh who reported true numbers were sacked because the sudden increase in cases indicated that they must have failed in their mission.

And the Director-General had even told countries that they could spend their smallpox eradication budget on better programs.

The smallpox eradication campaign introduced new technologies:

• Freeze-dried vaccine, which kept better in the heat.

• Bifurcated needles: cheap to produce, nearly painless, usable with 15 minutes of training, and so efficient that they quadrupled the number of people you could vaccinate with a single vial.

• Smallpox Recognition Cards: A guy in India who had the programmer virtue of laziness realized that he could save time on finding smallpox cases by teaching locals to recognize the rash. The cards were soon rolled out worldwide.

• “Ring vaccination”: identifying a case and vaccinating all their contacts, instead of vaccinating the entire population.

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The pilot of a WHO helicopter captured by Ethiopian rebels managed to vaccinate his kidnappers while awaiting rescue.

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In order to avoid offending the smallpox goddess Shitala, her worshippers in India refused vaccination. They also disposed of smallpox victims’ corpses in rivers, because it would insult her to cremate them.

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In Afghanistan, a third of all cases were caused by traditional variolation; the variolaters had to be convinced to stop and in some cases to take up vaccination.

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By 1973, smallpox had been chased back to its origins: major in India, Pakistan, Bangladesh and Nepal; minor in Ethiopia and Somalia.

In March 1971, the civil war over Bangladesh’s fight for independence sent a flood of 10 million refugees across the border with India and into horrifically overcrowded camps. One camp near Calcutta, holding about 250,000 people, was not checked for illness until Foege, home for Christmas and watching a television report on the crisis, spotted obvious smallpox cases among the refugees. Emergency vaccination began almost immediately but too late to reach the 50,000 refugees who returned to newly independent Bangladesh, where they unleashed an epidemic that tore through their homeland.

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I hadn’t quite realized before how coercive smallpox eradication was.

In Bangladesh, vaccinators chased down children hiding in trees and vaccinated them against their will and without their parents’ consent. Many other vaccinators in Bangladesh favored trains, because people couldn’t run away.

Villagers concealed smallpox cases, including babies under blankets, and sent children to hide in the fields when the vaccinators approached. Their main fear was loss of livelihood – people locked away in quarantine (guarded by sentries paid by the WHO) could not work, and neither could children with a sore arm following vaccination. WHO policy prevailed over the rights of the individual: dissenters were held down, but only for the few seconds needed to wield the bifurcated needle.

In Ethopia and Somalia, teams sat at watering holes and coercively vaccinated any nomads that came by.

I guess it had to be. If 90% of people want to be vaccinated, and you have to get everyone vaccinated… still, I feel uncomfortable about all the violations of bodily autonomy involved in this heroic achievement of humanity’s.

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Vaccinia major was eradicated in 1975 in India. Somalia and Ethiopia remained, because the government covered up smallpox outbreaks, and because their large nomad populations were hard to vaccinate. The race was on—minor had to be eradicated before the yearly pilgrimage to Mecca, which could spread it around the world and destroy all the WHO's work. Governments poured in money. Vaccinators swarmed.

Ali Maow Maalin was the last wild smallpox case in the world. He was a vaccinator and cook, and had never been vaccinated even though this was required for both of his jobs. He went into a jeep carrying two nomad children with smallpox to direct them to the isolation camp. Two weeks later, he fell ill with a fever. No one thought of smallpox for weeks and he wasn't isolated. Fortunately, no one else caught minor from him.

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The last smallpox deaths were from a lab leak in 1978. The WHO had ordered the closure of all labs that worked with smallpox without adequate safety precautions. Henry Badson’s lab had been working nonstop to finish its research before its ordered closure date.

On 5 September, Bedson had identified the specific strain of Variola major that had infected Mrs. Parker. Named ‘Abid’ after the three-year-old Pakistani boy from whom it had been isolated, it was the subject of research in his laboratory. The following day, Bedson was found at home with a suicide note and knife-cuts to his throat. He was rushed into the emergency unit and resuscitated, but too late to prevent irreversible brain damage; the painful decision was taken the next day to switch off his life support.

va... lid...?

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After two years and OVER NINE THOUSAND false alarms, smallpox eradication was judged complete December 9, 1979.

Smallpox eradication was planned to take ten years. Unfortunately—no surprise to the Director-General, I’m sure—they didn’t quite make the deadline.

It wound up taking ten years… and seven months.

Henderson had lapel badges made from a bifurcated needle bent into a circle to symbolise the long-awaited Target Zero. He sent a badge and a personalised citation certifying membership of the ‘Order of the Bifurcated Needle’ to all the international staff who had fought in the campaign....

Henderson also sent a tyre to the WHO mandarin who had sworn he would eat one if smallpox was ever wiped out. Like the insignia of the Order of the Bifurcated Needle, the tyre remained a perfect and unbroken Zero.

1. Variolation involves deliberately infecting someone with smallpox through applying smallpox scabs to a cut in their skin. Smallpox infections through the skin tend to be milder but still protect against future smallpox infections. The smallpox vaccination involved deliberately infecting people with cowpox or horsepox, mild conditions that are similar enough to smallpox that their antibodies also protecta gainst smallpox.