Kleio in Pandemia -
Covid-19 Blog of the Imre Kertész Kolleg

When Ibrahim Hoti came back from his pilgrimage to Ðakovica in Yugoslavia on 15 February 1972, the virus was already spreading in his body. Hoti felt it: everything ached, he developed fever and a rash without knowing what kind of infection he was suffering from. Two weeks later a teacher named Latif Mumdžić, who lived in the same town but was not in direct contact with Hoti, fell ill and went to the local medical center. Doctors treated him with penicillin, but it did not help. After a few days he was brought to the small hospital in a nearby town, but his condition did not improve. He was transferred to the central hospital in Belgrade, there the doctors assumed he was suffering an atypical reaction to penicillin, while in fact he was dying from variola major, a disease called the “speckled monster”, the “red plague” or simply smallpox.

It was this last outbreak of an epidemic in 1970s Yugoslavia that was often recalled by older generations when the Covid-19 pandemic reached the former Yugoslav countries and their governments executed massive measures to quarantine the citizens and detect those infected. This had been the last time when this region had found itself exposed to an unpredictable virus. From February until April of 1972, Yugoslavia experienced the biggest (and in fact, the last) outbreak of smallpox in Europe since the Second World War and managed to contain it. The media from Ljubljana, Slovenia, Zagreb Croatia and Belgrade, Serbia reported on the Yugoslav fight against smallpox and compared the measures of former communist Yugoslavia with the situation in their respective countries today. Many recalled an efficient and free health care system, a ‘strong state’ and trust in institutions as reasons for the success against smallpox. But how did Yugoslavia end that epidemic?

Smallpox is thought to have killed more people than any other infectious disease before it was officially declared eradicated by the World Health Organization in 1980. The disease was caused by a virus and was highly contagious, mostly transmitted by aerosols. It was often fatal, killing about 30 per cent of those infected. The first symptoms usually began to show 7 to 21 days after infection with fever, vomiting, back pain, and headache, and were followed by the symptomatic rash. Those infected transmitted the virus until the last skin lesion had healed. Since the Middle Ages doctors had tried and succeeded in dampening the fury of a pox epidemic by developing different kinds of immunization until Edward Jenner developed what he called a “vaccination” against smallpox. Yugoslavia’s last outbreak before 1972 had been in the 1930s, which is probably the reason the doctors did not recognize the disease immediately.

On 9 March, one day before Mumdžić died, the Belgrade doctors even showed him to staff and students to demonstrate his unusual case. From the moment of first infection, Mumdžić spread smallpox as he was transported from medical centres and hospitals from Kosovo to the capital of Yugoslavia infecting thirty-eight people. The next wave of infections was rolling in.

In Ðakovica, doctors became suspicious when complications associated with alleged chickenpox infections arose. On 14 March they were fighting for the lives of multiple patients when experts from the state institute of virology, vaccines, and sera arrived and tested them against smallpox. The following day, the doctors who were directly affected, select members of the communist party, as well as the American Central Intelligence Agency, knew that they were dealing with smallpox. The official reaction was silence. It is still unclear why the communist party waited one week to issue a statement and inform public about the existing smallpox epidemic. Did they not understand the urgency of the situation immediately? Were they trying not to jeopardize the tourist season in Dalmatia? The answer to this remains unknown. Certainly, the flow of information was controlled and intentionally opaque. In the first state television interview on 21 March, the Federal Secretary for Work and Social Policy, Vuko Dragašević, confirmed the existence of smallpox cases but emphasized that “there is no reason for panic, because the disease occurred just in some municipalities in Kosovo and it is not spreading”. At the same time, the Federal Task Force for the Fight Against Quarantinable Diseases was issuing orders to quarantine affected hospitals in Belgrade and other cities and to vaccinate the medical staff and residents in hopes that the outbreak would not spread further.

The Yugoslavs thought that they were prepared for the fight against smallpox. Plans already existed for the detection and isolation of patients and points of contact, widespread testing and progressive vaccination. The problem was that ‘patient zero’ was not detected at that moment, the background immunity level was not known, time was running out and the number of infections was on the rise. Nevertheless, a state of emergency was issued for the cities of Ðakovica, Orahovac and Prizren on 22 March. On 23 March, the decision was made to vaccinate all the citizens of Belgrade. In just two days 800,000 people were immunized, however they used an unsatisfactory vaccine that did not provide complete protection. In addition, Yugoslavia only had a total supply of one million doses – at the time of outbreak only 100,000 were in Serbia. The Federal Task Force realized that if they wanted to stop the epidemic they would have to ask for help and open their borders to the World Health Organization, more so, they would have to open up to the USA. And so, they did. The United States Centre for Disease and Control sent an observer into Yugoslavia on 26 March and four days later sent a team for epidemic aid led by Dr J. Michael Lane who would later become the director of smallpox eradication at the US Centre for Disease Control. In total, Yugoslavia acquired 14,336,000 doses of the vaccine from other nations ranging from 60,000 from Eastern Germany to 3,500,000 from China. Secretary Dragašević was “exceedingly grateful for the prompt and generous assistance provided by the US Government, which included 3 million doses of vaccine, the services of the 7 US epidemiologists and the use of 24 vaccination guns”.

Once the decision was made, the public informed and the help organized, the Yugoslav health service efficiently combated the outbreak with support of the Yugoslav National Army. Donald A. Henderson, chief of the World Health Organization’s global smallpox eradication program flew to Belgrade and provided first-hand evidence of Yugoslav efforts: “they stopped cars along the road to vaccinate people; they went from village to village, vaccinating almost the entire country – 18 million out of 20 million people”.

Local lockdowns were ordered, all sporting events were cancelled, local emergency hospitals and quarantine wards were organized, but the borders remained open. Despite the tremendous effort made to find all the contacts of those infected, Ejub Hodžaj, a friend of Ibrahim Hoti’s brother, was able to leave for Hannover before being detected with smallpox. Hannover quarantined nearly 645 people, and health officials – working in shifts together with army doctors at 11 vaccination centres – vaccinated more than 70,000 people. Hodžaj survived and remained the only German case.

The smallpox epidemic disclosed different organizational, cultural, and administrative problems in Yugoslavia. The CDC report points out that the decentralization of decision-making and administration in Yugoslavia and the lack of information had a major impact on the outbreak control activities. However, Yugoslavs quarantined contacts efficiently and rigorously and the outbreak was rapidly controlled once the diagnosis was confirmed. Although the widespread mass vaccination was ordered without a complete epidemiological assessment of the situation, it did stop the epidemic.

The outbreak involved 174 cases, including 35 deaths. The case fatality rate was 35 per cent in the unvaccinated, and 9 per cent in those with the scars of old vaccinations. Since March 1972, the new vaccination scars that appear on the upper arms of Yugoslav citizens can be seen as a demonstration of the collective effort in the fight against the disease. A disease that frightened the Yugoslavian people and their political leadership to the bone.

As American observers stated, Yugoslavia’s health system was not as efficient as older generations remembered. Also, the Yugoslav response to the outbreak was not as good as they remember it to be. But the political system benefited from trust in the government, trust in the health care system and trust in the institutions. In ethnic Albanian dominated regions where people did not trust the government, the measures were implemented significantly worse than in other parts of Yugoslavia.

At the beginning of the Covid-19 pandemic, the citizens of the former Yugoslav republics accepted the strict measures of their governments almost without protest. But very soon their confidence was failing. From 7 till 9 July, thousands of Serbians joined nightly anti-government protests in Belgrade. They were demonstrating against measures to counter a second wave of Covid-19, which included a new three-day lockdown. Protesters clashed with the police violently, throwing bottles, fireworks and rocks and breaking in to the parliament building. The riot ended after Serbian President Aleksandar Vučić confirmed that the curfew would not be reintroduced. There is no available vaccine against Covid-19 right now. However, the question remains, if there was a vaccine, would ex-Yugoslavs reach out their arms once again?