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Commentary 

Volume 13 (Suppl.)       Number 32     December 2020  
Copyright © 2020 Tehran University of Medical Sciences. 
This work is licensed under a Creative Commons Attribution-NonCommercial 
4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/).  
Non-commercial uses of the work are permitted, provided the original work is 
properly cited. 

COVID-19 and collective responsibility: a lesson from the smallpox 

outbreak in Moscow in 1960 

*Corresponding Author 
  
Yana G. Grigoryan 

B. Patriarchiy Per., No.3, St. No.1, 

Moscow 123001, Russia. 

Tel: (+7) 91 65 96 56 70 

Email: grigoryan.yg@1msmu.ru 

 

Received: 19 Nov 2020 

Accepted: 15 Dec 2020 

Published: 28 Dec 2020 

 

Citation to this article:  

Grigoryan YG, Krylov NN. COVID-19 

and collective responsibility: a lesson 

from the Smallpox outbreak in Moscow 

in 1960. J Med Ethics Hist Med. 2020; 

13(Suppl.): 32. 

 

Yana G. Grigoryan1*, Nikolay N. Krylov2 
 

1.Associate Professor, Department of Humanities, The I.M. Sechenov First Moscow State Medical University (Sechenov 
University), Moscow, Russia. 
2.Professor, Department of Humanities, The IM Sechenov First Moscow State Medical University, Moscow, Russia. 

 

 

The COVID-19 outbreak has been an unprecedented challenge 

for modern countries. The pandemic has spread around the 

world in several months and has already claimed more than 1.75 

million lives (1). The most important question all countries 

around the world have to address is how to protect people from 

infection in a safe, equitable and effective manner. 

Russia is among those countries that have responded to the 

pandemic by introducing severe restrictive measures in the 

country. Upon announcement of the lockdown on March 25, 

2020, people were advised not to go out. Individuals over 65 

stayed home and could only go to the grocery store, bank or 

pharmacy. Schools, universities, concert halls, libraries, cafes 

and restaurants closed down. It was impossible to use public and 

private transportation without a special electronic pass issued by 

the authorities. International travel control was introduced and 

borders were closed.  

As a result of this policy, the society has been divided into two 

warring camps. People from one camp were in denial about the 

virus threat. They did not feel threatened by infection, 

demonstratively disregarded preventive measures, deliberately 

broke the rules imposed by the state and wanted to live their 

ordinary lives. Those in the other camp demanded strict 

compliance with all the restrictions imposed on themselves or 

others and did not allow any compromises.  
 

 



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Volume 13 (Suppl.)     Number 32     December 2020 

 

Disputes between the two have raised the 

question of what measures can be taken to 

quickly limit the epidemic, and where the 

dividing line between the interests of the 

society as a whole and the personal rights of 

the individual citizen is. 

Over the past few decades, public health 

ethics experts have come to the conclusion 

that “the conceptual resources for clinical 

ethics are inadequate for dealing with issues 

in public health practice” (2). Numerous 

studies based on Beauchamp and Childress' 

key text “Principles of Biomedical Ethics” have 

addressed to a great extent the moral issues 

concerning professional-patient interactions 

based on the principles of autonomy, 

beneficence, non-maleficence and justice (3). 

By contrast, public health programs aim to 

preserve and promote health at the level of 

the entire population, so the methods used to 

maintain the public good may violate some 

ethical principles. This is due to the key 

difference between public health and clinical 

medicine, which is the preventive nature of 

the former. In the face of infectious disease 

threats, public health often aims to impose 

restrictions on healthy people who are the 

potential victims of the disease but do not 

suffer when these restrictions are applied. 

The emerging ethical dilemmas of public 

health therefore go beyond the established 

consensus in most contemporary bioethical 

norms. 

This article aims to reflect on what ethical 

constraints are permissible during an 

epidemic, and what these constraints are 

dependent on. This perspective is historical, 

represented by the history of the smallpox 

outbreak in Moscow in 1959 - 1960, in the 

context of which the authors analyze the 

principles that justify public health 

intervention during the COVID-19 pandemic. 

By comparing approaches to public health in 

the two epidemic situations, the authors 

offer arguments justifying the need to 

recognize the moral obligations of citizens to 

each other to protect the society from threats 

to health and safety. 

Vaccination against smallpox began in 1801 

in Russia, when a well-known doctor, Efrem 

O. Mukhin (1766 - 1850), vaccinated a boy 

against cowpox in a Moscow Educational 

Home. As in other countries, vaccination in 

Russia first met with resistance from part of 

the population, but after a while the method 

became widespread. Before the 1917 

revolution, however, vaccination was not 

compulsory in Russia. The decree of the 

Council of People's Commissars of the 

Russian Soviet Federative Socialist Republic 

(RSFSR) “On Compulsory Vaccination”, 

signed by Vladimir Lenin on 10 April 1919, 

and the new Law on Vaccination and 

Revaccination of 1924 made vaccination in 

the country strictly observed. Thanks to 

these measures, smallpox was considered to 

have been defeated in the Union of Soviet 

Socialist Republics (USSR) in 1936 (4), but 

after 23 years, a dangerous disease that 

everyone had forgotten about returned. 

In this case, patient zero was a Soviet poster 

artist, Alexei Kokorekin, who contracted 



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Volume 13 (Suppl.)       Number 32     December 2020  

smallpox in India in 1959. The contagion 

was caused when Kokorekin purchased the 

carpet of the late Indian Brahmin after 

attending a traditional Indian funeral (5). 

Upon returning to Moscow on December 23, 

1959, he felt unwell. On December 27 the 

patient was hospitalized in the Infectious 

Disease Unit of Botkin Hospital, where he 

died on December 29. On the same day, 

after an autopsy, doctors suspected toxic 

plague. On December 31 the body was 

cremated in accordance with the 

requirements for particularly dangerous 

infections (6).  

On January 11, 1960, doctors began to 

register people with natural smallpox in 

Moscow. Doctors could establish a 

connection between smallpox and the 

deceased artist only 13-16 days after 

Kokorekin's death. His medical record stated 

that he had received a smallpox vaccine two 

weeks before he left for India, but did not 

have a vaccine reaction. 

The government decided not to inform 

Muscovites about the threat of the epidemic 

to avoid panic among citizens. Instead, all 

available resources in the city including 

hospitals, clinics, police, military and so on 

were immediately mobilized to combat the 

deadly threat. All efforts were focused on 

finding the people who had come into 

contact with potential carriers of the virus. 

Epidemiologists identified three foci of 

smallpox: the first was discovered in the 

artist's family, and the second in the hospital; 

the third source of infection, however, was 

the most dangerous. It included everyone 

who had contacted the infected people, but 

had not been found. The number of these 

people could have been huge and was 

growing by the minute. Everyone who was 

involved in the search for infected 

individuals worked around the clock. 

Between January 16 and 31, investigators 

found and isolated 9,342 people. Although 

several hospitals were designated as 

quarantine centers, there were not enough 

beds for all those who were infected.  

The medics sorted all those people into two 

groups. The first group included 1,500 

people who had personally communicated 

with the infected. They were isolated in 

hospitals in and outside of Moscow. The rest 

of them were locked in at home. For all 14 

days of quarantine, doctors examined them 

twice a day. In addition, all the suspicious 

places in the capital were disinfected. At the 

same time, the authorities urgently began 

producing smallpox vaccines in quantities 

that would meet the needs of the entire 

population of the country. The 

epidemiological situation forced the Soviet 

government to start mass immunization of 

the population as soon as possible. The main 

stage of primary vaccination was held from 

January 18 to February 1, 1960. During this 

time, 6,187,660 people were vaccinated. A 

total of 46 people became sick with 

smallpox that year in Moscow, and three of 

them died. An outbreak of smallpox was 

fully localized by February 6, 1960. Forty-

four days passed between the beginning of 



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Volume 13 (Suppl.)     Number 32     December 2020 

the infection and the end of the outbreak.  

While the case of the smallpox infection in 

1960 differs from the current pandemic in a 

key detail, that is, the availability of a 

vaccine, similarities can still be traced. In 

2020, the state faced a highly contagious 

virus that claimed thousands of human lives. 

On both occasions, the state took various 

restrictive measures to prevent the spread of 

the disease. A brilliant result in the fight 

against the smallpox epidemic in 1960 was 

achieved through the restrictive measures 

imposed by the Soviet government, the 

urgent comprehensive diversification of all 

medical resources and the creation of 

additional medical capacity, as well as the 

introduction of strict infection control not 

only in hospitals but also in the apartments 

of sick people. Soviet doctors could not 

manage smallpox in time for the first patient, 

because there had been no cases of this 

disease since 1936 in the USSR. However, 

careful monitoring and quarantine, an 

epidemiological check-up, contact tracing, 

isolation and subsequent mass vaccination of 

patients turned the situation around and led 

to a victory over the epidemic. 

In 1960, the Soviet authorities refused to 

inform the general public about the smallpox 

outbreak in Moscow, which cannot be 

considered an appropriate measure for the 

fight against the pandemic in 2020. Already 

at the beginning of the pandemic in April 

2020, over 86% of the Russian population 

had all the necessary information about the 

virus and its transmission (7). However, 

understanding how the infection spread did 

not prevent citizens from leaving the capital 

after the introduction of social distancing 

and self-isolation. This escape from the 

city's closed flats to the country contributed 

to the possible spread of infection from 

Moscow, which was the center of the 

infection, to other regions and districts. 

Another problem was the citizens' 

unwillingness to comply with the self-

isolation regime after returning from abroad, 

where the pandemic was already raging. 

This made it difficult for epidemiologists to 

identify the outbreak of COVID-19 and 

reduced the ability of state services to 

control its spread. 

To avoid the consequences of such 

irresponsible behavior or spontaneous and 

unconscious actions, in 1960 the Soviet state 

assumed full responsibility for measures to 

combat the spread of the disease and save 

lives. By implementing a paternalistic model 

of relations, the state acted as “guardian”, 

assuming full responsibility for the outcome 

of an outbreak of a particularly dangerous 

infection. It proceeded on the assumption 

that the doctor knew better than the victim of 

infection what was good for his/her health. 

In this case, the opinion of citizens was not 

taken into consideration, since most people 

had little knowledge about the disease and 

its dangers, no knowledge about prophylaxis 

and treatment, and limited ability to choose 

an effective method of fighting it.  But these 

government actions deprived citizens of 

their rights and made them victims of a 

policy of diktat. Yet, this demonstration of 

power of the state machinery to enforce 



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Volume 13 (Suppl.)       Number 32     December 2020  

quarantine also had the opposite effect. It 

deprived the population itself of the opportunity 

to demonstrate active citizenship, civic virtue, 

moral responsibility, and participation and 

concern for the public good. It extended 

mistrust, disrespect and inequality toward the 

very institution of the society as a 

community of socially responsible 

individuals whose personal well-being and 

personal values are inextricably linked to the 

values and well-being of others. 

In 2020, COVID-19 has demonstrated the 

pivotal role of public values in governance 

(8). Many states, including Russia, have 

refused the toughest scenario in fighting the 

spread of the pandemic and shared 

responsibility for its spread with the society. 

The lack of a vaccine, high contagiousness 

of the virus, and the large number of 

asymptomatic infected people meant that 

social distance was crucial in combating the 

spread of the virus and preventing the 

collapse of the healthcare system. 

This could be achieved through cooperation 

and voluntary subordination. To accomplish 

this, citizens must demonstrate a high level 

of altruism, which is the desire and ability to 

sacrifice their values for the benefit of others 

or the society as a whole. But unfortunately, 

this is not what has happened. Many people 

ignored the self-isolation requirements after 

returning from a COVID-19 hotspot. Many 

others refused to wear masks or maintain 

social distancing because of the 

inconveniences caused in their daily routine. 

Finally, people refused to maintain isolation 

because they believed that the state had no 

right to restrict civil liberties. As a result, we 

have seen a sharp increase in the number of 

COVID-19 patients, since such violations 

have triggered a new round of pandemic 

development (9).  

Effective social distancing could also be 

achieved not through trust, but through 

coercion, for example high fines or threats of 

imprisonment for violators. This method has 

shown its effectiveness in China and other 

countries (10). In this case, however, it was 

inevitable that the state would disregard 

citizens' personal freedoms. Consequently, 

in the absence of a vaccine and other 

effective means to prevent the spread of the 

disease, any government action to combat 

the pandemic turns into a search for the 

optimal balance between strategies to lower 

the rate of morbidity and mortality, and 

severe restrictive measures imposed by the 

government. According to this logic, the 

more people ignore social distancing 

measures, the more intolerant the 

government should be of those who violate 

the established rules of conduct.  

COVID-19 has therefore posed a 

complicated ethical dilemma for the society 

in finding the optimal balance between 

individual impulses and freedoms, and the 

collective responsibility. Should the society 

come to terms with restrictive measures 

during the epidemic? In an epidemic, are 

personal rights and freedoms as valuable as 

the lives of others? 



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Volume 13 (Suppl.)     Number 32     December 2020 

It is the general belief that limitation or 

infringement of civil rights and freedoms 

cannot exist in democratic states, but that is 

not true. Danielle S. Allen believes that one 

of the harsh truths of democracy is that some 

people always give up something for others 

(11). It is no accident that people often find 

themselves in a state of disagreement with 

the political decisions of the state. What they 

will have to give up is certainly valuable to 

them, but they agree to give it up for 

something higher, that is, the common good. 

Therefore, one of the harsh truths of 

democracy is that it requires sacrifices for 

the sake of others (12). 

The only way to deal effectively with this 

issue is to build a relationship based on trust 

among the citizens so that they can be sure 

that their sacrifice is reciprocated. Social 

distancing measures will only be effective if 

each citizen realizes that he/she is 

responsible not only for himself/herself but 

also for others. Individualism is a threat to 

human lives among members of the society 

as atomistic bearers of interests, preferences 

and desires who are expected not to seek to 

enter into social relations with one another 

during the COVID-19 pandemic. If the 

world states cannot cope with the pandemic, 

the society should not stay aside. In the face 

of uncertainty, collective responsibility and 

its limitations remain the only way to defeat 

the disease for now. In addition to the 

elaborate ethical principles of autonomy, 

rights, freedom and well-being or welfare of 

the individual, public health ethics depends 

on the principles of virtue, reciprocity, 

justice, solidarity and collective 

responsibility (13). However, it has become 

increasingly clear that the society is not 

prepared to make such sacrifices. COVID-19 

has become a serious crisis of collective 

thinking about the basic values of 

democracy and solidarity. This is evidenced 

by the second wave of the pandemic and the 

steady increase in the number of victims of 

the epidemic. 

The smallpox epidemic in Moscow in 1960 

showed that a quick and effective response 

to the epidemic is associated with a 

restriction of civil rights and freedoms. In 

the case of COVID-19, the state shares 

responsibility for fighting the pandemic with 

the society, and members of the society must 

be prepared to sacrifice some of their 

individual rights and freedoms for the lives 

of others. The priority of collective values, 

responsibility and solidarity can be the most 

effective weapons in the fight for survival. 

 

Conflict of Interests 

There is no conflict of interests to be 

declared. 

 

  



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