In 1971 I was a surgeon on the ocean liner P&O Orkney. Early Christmas morning the phone rang, could I go see someone with a strange rash? The patient was from Goa, and he belonged to a group of 20 people who had been flown to Singapore about 5 days ago to relieve others who had to leave. His problem was spots and a mild fever. They were in the arms and chest of the young man, raised from the surface of the skin, with a central dimple, and in medical jargon ‘umbilicados’. This was a huge leap from treating motion sickness.
All the internal red lights lit up at once. The differential diagnosis was both mundane and terrifying. Chickenpox was the favorite, followed by insect bites or a kind of skin infection commonly called impetigo, but and it was a big but, the spots themselves matched the classic description of smallpox in textbooks. Was there smallpox where did it come from? It was still very early in the morning, around 7am, and the ship was finally fixed and it was on its way to a stop at a premier tourist spot on the Great Barrier Reef, Hayman Island. It was a good 2 days sailing. Now smallpox anywhere is a terror, on a passenger ship it is a disaster of Hollywood proportions. Smallpox is one of the most infectious diseases that we know of, it also has a really terrifying mortality, ranging from almost 100% to the best 20-30% depending on the strain of the virus and the susceptibility of the community it attacked. In recent years we are used to thinking of it as a weapon of terrorism since the disease itself was annihilated by the WHO vaccination program, the last non-laboratory case being in the early eighties. Even at the time of writing it was rare and limited to poor populations in hot countries.
He needed to isolate himself. We were lucky in that regard, the ship’s hospital was located above the propeller on deck C aft. There was a small free-standing room designed precisely for this purpose, known as the Brig, as it also functioned as a cell in case the need for restraint arose from an aggressive crew or passenger.
We then radioed with Darwin Port Health, who said we couldn’t go back and suggested talking to authorities in Brisbane. Finally the captain spoke briefly and I was handed the radio to speak with the Australian medical director. He was a man who seemed angry and with no discernible sense of humor, not that the situation was funny. He insisted that everyone on board must be inspected 24 hours, but every 12 hours within 48 hours of arrival ashore and yes, everyone on board without a valid certificate must be vaccinated, excuses are not tolerated. He gave the impression that he was as sure as he could that our diagnosis was wrong and that it was probably a storm in a teacup and of course it was just chickenpox in an Asian man. We were to move from Australian Territorial Waters and head to Brisbane for further instructions.
The CMO had insisted that only the ship’s doctors could do the inspections, but the nurses could help with the vaccinations. There were only 2 doctors, 2 nurses plus Ron, the former naval dispenser, who counted as a nurse as far as I’m concerned. Fortunately, there was already a routine pre-dock inspection in Australian ports. Port Health ruled that any ship from non-Australian ports must undergo a full smallpox inspection before being allowed to dock, so we were used to doing such inspections. There was an established routine, and even an expectation from both passengers and crew, but doing it for four days, twice a day for the last 2 days, was going to test everyone’s patience.
From a medical point of view, we decided to combine the first inspection with mass vaccination; We did the crew first to put our hand out so to speak. We decided to vaccinate the entire Goan crew regardless of what their smallpox certificate said. This was because to a man they were all notorious enemies of needles and it was well known that most certificates were forgeries. It was a cottage industry in Goa. Vaccination was performed by placing a drop of serum on the skin, and scratching two parallel lines at right angles and rubbing the material into the scratches with a needle. It was not a painful procedure, but the reaction of many would deny that fact, we do not tolerate excuses no matter how elaborate.
We finally arrived in Brisbane and were also instructed to wave two yellow flags. Normally only one yellow flag was flown before being approved by Port Health, two yellow flags meant we were a dangerous outcast. Our patient was tied up like a cooked chicken, unceremoniously grabbed, thrown into the cart, and rushed away, the breathing tube sticking out of the wrapper. It looked like an insect chrysalis. We never saw him again. Although we made several inquiries, the Brisbane Port Health Authority never confirmed it as smallpox, but they also didn’t say it wasn’t. I remain convinced that we saw the last case of smallpox on a passenger ship.