Book review: “The Last Days of Smallpox: Tragedy in Birmingham” by Mark Pallen

11th August 2018 marks 40th anniversary of the last outbreak of smallpox in Britain. Smallpox is one of the worst and most thoroughly forgotten infectious diseases. Infection with variola major virus causes around 30% death rate, not much lower than for plague and ebola and frequent disfigurement because of the pox scars concentration on the face. Many a classic literature book mentions a character – a villain or a beggar – covered with pox marks.

But as a result of the global eradication programme, the last natural case of the pox was reported in 1977. I still have s skin bump of pox vaccination on my left hand. It would allow determining my age if necessary, but present generation knows nothing about the former killer.


A case of smallpox, 1886. (Image via Wikimedia Commons)

The book is based on the author’s experience in virology – he is a Professor of Microbial Genomics at the University of Warwick, UK – and his research in archives and interviewing witnesses. The book is a cross between a detective story with horror elements and a procedural in the vein of John Grisham’s novel.

The book strong points are in the description of smallpox origins, epidemiology, history of treatment and the Birmingham incident. From the hindsight health and safety procedures a mysterious case of pox infection of the medical photographer who was vaccinated and shouldn’t have been nowhere near the live virus read like a horror story – no airlock in the lab that worked with the most dangerous infections, mouth aspiration of human pox virus.

Additionally to summarising the government report on the case and the trial (which the author allows to skip, but I don’t recommend it) the book offers a new and highly plausible hypothesis of the accident.

However, unlike other reviewers that awarded the book five stars, I cannot say that the book is perfect. While the epidemiology and disease cases described vividly, a brief description of the virus and its mechanism of action beyond “its genome is too big to use in bioweapons” would have been useful. It’s mentioned that vaccination had its own drawbacks, but there’s no explanation of how a live vaccine works. The reassurance that just as microbiological practices have improved significantly much since the accident, the vaccines have also improved wouldn’t have gone amiss.

The story would have benefited from a few of the tricks of thrillers. For example, the parade of pox cases would have benefited from joining them into the narrative and teasers along the lines “This case will be an important argument for prosecution in the Birmingham trial.”

The personal interludes, interspersed with the main narrative, become more and more self-indulgent. For example, there’s a meandering narrative about going to pubs and meeting ‘who is who’ of microbiology, the punchline being that the last encounter is close to one of the very few remaining deposits of the smallpox samples. I would have instead read instead about more cases in an Appendix

However, all the “buts” are mostly to explain the four-star verdict. All in all, a very worthy book that may be a sleeper – not many people are interested in “historical diseases” – but extremely valuable for the future researchers.