Warning – this story contains graphic images.
In the summer of 1978, the last known case of smallpox was reported, claiming the life of 40-year-old medical photographer Janet Parker. But how did the disease, thought to have been eradicated across the world, come to be in Britain's second city?
It was Friday 11 August when Janet Parker first began to feel unwell.
Within days, Mrs Parker, a medical photographer in the anatomy department at Birmingham Medical School, had developed unsightly red spots on her back, limbs and face.
When the doctor was called, she was told she had chickenpox.
But Mrs Parker's mother, Hilda Witcomb, was sceptical. She had nursed her daughter through the virus as a child, and the large blistering pustules now appearing on her body were markedly different.
With no signs of improvement, a hospital appointment was arranged and the 40-year-old was admitted to the Catherine-de-Barnes Isolation Hospital in Solihull on 20 August.
By now Mrs Parker was so weak she could not stand unaided.
"I do remember thinking she was very poorly, she had a very dramatic rash," said Prof Deborah Symmons, the first member of medical staff to see Mrs Parker when she was admitted.
"It was widely thought the last [smallpox] case had occurred."
As Prof Symmons examined Mrs Parker, it was only then the dreaded word "variola" – the scientific name for the disease – made it on to her medical notes for the first time, and soon the doctors' worst fears were confirmed.
Smallpox, the last natural case of which anywhere in the world had been reported in Somalia in 1977, was back – in Birmingham.
An ancient disease in existence for thousands of years, smallpox was feared throughout the world.
Killing a third of those it infected, in the 20th Century alone an estimated 300 million people died from the disease.
Those who were infected but survived were often left badly scarred.
A global vaccination programme, led by the World Health Organization (WHO), was carried out to wipe out the disease and by the 1970s cases were rare.
And in 1978 the body was just about to declare it eradicated on a worldwide level.
The last place anybody expected it to break out was in the UK, which had not seen an identified case of the disease for five years before Mrs Parker. The impact of its return was felt on a global scale.
"It was huge. Smallpox was about to be declared eradicated, people knew that was about to happen," said Prof Alasdair Geddes, who was a consultant in infectious disease at East Birmingham Hospital at the time of the outbreak.
"It was a feared disease; it wasn't just a panic in Birmingham, there was panic in the government and the WHO of it just reappearing."
On hearing of the Birmingham case, the WHO wasn't taking any chances. The organisation – and the media – descended on the city.
"Very very quickly, national and then international press appeared" and it became a "major worldwide issue", said Prof Geddes.
"There was of course a heavy presence from the WHO. They were obviously very concerned.
"The incubation period for smallpox is quite long, it's about 12 days, so we had really about a fortnight's anxiety to whether there were going to be any more cases."
As the medical teams jumped into action, those closest to Mrs Parker were among the first be vaccinated and quarantined.
Her husband, Joseph, and parents Hilda and Frederick Witcomb, were questioned about their recent movements, for fear the disease could spread further.
All those who had come into contact with Mrs Parker were treated similarly – from the man who came to fix the bedpan washer, ambulance staff, the hospital chaplain and the GPs who had seen her out in the community.
By 28 August, just two weeks after Mrs Parker had first shown symptoms of the disease, more than 500 people had been vaccinated.
But one question on everyone's mind remained: how had she been infected in the first place?
Prof Henry Bedson headed the smallpox laboratory at Birmingham Medical School – where Mrs Parker worked – one of only a handful commissioned by the WHO to research the disease.
Prof Bedson joined Prof Geddes on the night Mrs Parker was diagnosed with the disease and helped examine her test samples.
"I said 'can you see anything Henry?', and he never answered," said Prof Geddes. "So I gently moved his head aside so I could look down the microscope and there were brick-shaped particles that are characteristics of the smallpox virus.
"He was horrified, because there was little doubt that in some way the smallpox virus had escaped from his laboratory and had infected Mrs Parker."
"I think as soon as he saw it he knew somehow it had come from his lab. He knew what would follow," Prof Symmons said.
"Given the circumstances, where else could it have come from? One theory is that it got in the venting, but if that was the way, why only her?"
The spotlight fell on Prof Bedson, says Prof Mark Pallen, author of The Last Days of Smallpox: Tragedy in Birmingham.
And the 49-year-old professor, a recognised international expert on the disease, was left "distraught" by the outbreak.
"There was a media scrum, people were camped outside Bedson's house. He was working to rid the world of smallpox, he's a hero," Prof Pallen says.
As the days went on and Mrs Parker remained in isolation, her condition deteriorated.
She was left almost blind in both eyes from the sores and doctors believed she had gone into renal failure.
As the disease took hold, Mrs Parker developed pneumonia and stopped responding to people verbally.
As she lay in her hospital bed, on 5 September her father Frederick, 77, died from an apparent cardiac arrest while in quarantine, thought to have been brought on by the stress of his daughter's illness.
However, no post-mortem examination was ever carried out due to the risk the smallpox infection posed.
With the outbreak claiming its first victim, a day later Prof Bedson went out into his shed at his home in the Birmingham suburb of Harborne and killed himself.
He left a note, which read: "I am sorry to have misplaced the trust which so many of my friends and colleagues have placed in me and my work."
Five days later, at 03:50 on 11 September, Mrs Parker died.
The disease had claimed its final victim.
While Mrs Parker's mother developed "a very mild attack of smallpox" according to Prof Geddes, she was discharged free from infection on 22 September.
She had missed the funerals of both her husband and daughter.
Birmingham was declared free of the disease on 16 October 1978, but the question as to exactly how Mrs Parker contracted smallpox has never been answered fully.
In October 1979, three judges at Birmingham Magistrates' Court dismissed the prosecution's evidence that the University of Birmingham had contravened the Health and Safety at Work Act.
In the eyes of the law, Prof Bedson had been exonerated.
In 1980 a government-commissioned paper, the Shooter Report, found there was "no doubt" that Mrs Parker had been infected at the laboratory.
The report said the transfer of the virus must have occurred by one of three routes – on an air current, by personal contact or by contact with contaminated equipment or apparatus.
However, the theory that it was spread in the air duct "was not really believed by anyone in the know", Prof Pallen says.
"Why did she die, why did she get it so badly?" Prof Symmons still wonders, but she adds: "If we couldn't find out what happened 40 years ago, it won't suddenly become clear now."
As time moved on "everything went back to normal", adds Prof Symmons.
To date, there have been no further outbreaks of the disease.
In 1980, two years after Mrs Parker's death, smallpox was officially declared to have been eradicated. The disease had been defeated by medical science.
It was the first infectious disease to have been fought on a global scale.
The feat was an extraordinary achievement accomplished due to countries collaborating across the world.
As Prof Lawrence Young from Warwick Medical School said: "This was a disease that had desperate effects on individuals, because it marred you for life, it caused disfigurement, so getting over the disease and being able to eradicate it was an enormous achievement."
Edward Jenner – the pioneer of the smallpox vaccination
Edward Jenner was an English scientist who lived in the 18th Century. He discovered the first vaccine, which was for the smallpox virus.
In 1796 Jenner noticed that milkmaids who had caught the cowpox virus did not normally then catch smallpox. Cowpox was very similar to smallpox but less contagious.
He collected pus from the cowpox blisters on a milkmaid's hands and purposefully infected a small boy.
The boy was taken ill for a short while, but was then resistant to any subsequent infections of the cowpox and smallpox viruses.
He tested this by infecting the boy with smallpox and no illness occurred. Jenner was therefore the first person to vaccinate someone against infection.
Additional reporting by Lisa Wright
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