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INTERNATIONAL HEALTH AND THE LIMITS OF ITS GLOBAL INFLUENCE: BHUTAN AND THE WORLDWIDE SMALLPOX ERADICATION PROGRAMME

Thursday, 30th of July 2015

INTERNATIONAL HEALTH AND THE LIMITS OF ITS GLOBAL INFLUENCE: BHUTAN AND THE WORLDWIDE SMALLPOX ERADICATION PROGRAMME

Sanjoy Bhattacharya ^*

This article has been cited by other articles in PMC.

Excerpts below; full text, with table, is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865968/

Abstract

Histories of the global smallpox eradication programme have tended to concentrate on the larger national formations in Africa and Asia. This focus is generally justified by chroniclers by the fact that these locations contributed a major share of the world annual tally of variola, which meant that international agencies paid a lot of attention to working with officials in national and local government on anti-smallpox campaigns in these territories. Such historiographical trends have led to the marginalisation of the histories of smallpox eradication programmes in smaller nations, which are presented either in heroic, institutional tropes as peripheral or as being largely shorn of sustained campaigns against the disease. Using a case study of Bhutan, a small Himalayan kingdom sandwiched between India and China, an effort is made to reclaim the historical experiences in small national entities in the worldwide smallpox eradication programme. Bhutans experience in the 1960s and 1970s allows much more in addition. It provides us with a better understanding of the limited powers of international agencies in areas considered politically sensitive by the governments of powerful nations such as India. The resulting methodological suggestions are of wider historical and historiographical relevance.

Introduction

The worldwide programme to eradicate smallpox started gathering momentum in the latter half of the 1960s, after the creation of an energetic coordinating body at the World Health Organization headquarters in Geneva (WHO HQ). This office was able to mobilise unprecedented levels of political and financial support internationally. Whilst the successes in Western Africa had raised the profile of the fight against the disease in administrative circles within the United States of America, it was obvious to almost everyone supportive of smallpox eradication that a genuinely global effort would need to be rooted in the South Asian subcontinent; here countries such as India, Pakistan and Bangladesh regularly contributed the bulk of the worlds cases of variola. ¹ The West African campaign, which was coordinated by the United States Centers of Disease Control (CDC) and supported by the United States Agency for International Development (USAID), coincided with efforts to crank up the effectiveness of existing smallpox eradication programmes in South Asia (activities that were spurred on by funds provided by the WHO and the governments of India and Pakistan). This included some successful pilot projects in India with support from its federal and state governments; it is, therefore, difficult to make definitive statements about whether one regional campaign helped develop another, even if some institutional histories and memoirs seem extraordinarily confident in their claims in this regard. ²

With Donald A. Henderson as Director, the WHO HQ-based coordinating unit entered into detailed negotiations with national governments across the world. The support mobilised ebbed and flowed over time, and this experience presented WHO officials with a steep learning curve, and forced them to face up to several harsh lessons about the complexity of local administration and politics. These experiences, as well as the difficulties created by largely autonomous WHO Regional Offices that were divided about the wisdom of providing unquestioning backing to the goal of smallpox eradication, helped Hendersons unit recognise the need to remain adaptable towards the crystallisation of multifaceted national programmes. ³ This enabled his associates and him to advocate a less top-down style of management, which was welcomed at least by some international workers deployed by the WHO worldwide. These were WHO nominees who had been consistently open to exchanging ideas with medical, paramedical and health officials responsible for running local administrative structures; people who generally refused to make rash presumptions about the abilities and attitudes of governmental staff, chose their local allies carefully and were adept at fostering community stake-holding. New and more reliable information flows about the actual levels of smallpox incidence were a result, which helped the production of a more accurate picture of the challenges facing the eradication programme in myriad locales. Where implemented, these policies allowed for the more efficient distribution of personnel, vaccines and funds; despite the ups and downs of individual projects, these trends contributed significantly to the falls in smallpox incidence across South Asia that were witnessed between 1970 and 1975. ⁴

However, it would be incredibly simplistic to assume that these changes were embraced both universally and uniformly, and that all international workers behaved in the same way; like the efforts of their governmental counterparts, the work carried out by overseas personnel was marked by varying levels of commitment, openness and efficiency. It is also important to remember that the experiences within smaller nations in the South Asian subcontinent such as Bhutan, Nepal and Sri Lanka were rather different from those witnessed in India and Bangladesh, which were major reservoirs of the variola virus. Specificities in relation to geographical factors, national politics, international pressures, social profiles, and infrastructural and economic conditions were important determinants of how smallpox eradication programmes were developed and run. Yet, there is surprisingly little recognition of the distinctiveness of national and local campaigns across the South Asian subcontinent in the generalising narratives available to us. ⁵ In relation to Bhutan, the focus of this article, it is worth noting here that the official WHO histories have struggled to provide more than a few paragraphs or pages on its experiences, and that the accounts are not particularly fulsome. For instance, the flagship history of the Indian case study prepared by the WHO Regional Office for South East Asia (WHO SEARO), which was published in 1979, manages to describe the entire history of the kingdoms programme in the following paragraph:

From 1954 to 1965 no smallpox case was reported in Bhutan. In 1966 forty cases resulting in 20 deaths were detected. This outbreak resulted from importation of infection among newly recruited labourers coming from India. Apart from one importation in 1974, no other smallpox cases have been reported during the period 1967–75. In view of the recent endemicity of smallpox in neighbouring countries and the relatively free movement of the population between India and Bhutan, an intensified smallpox surveillance programme was organized in the second half of 1976. In autumn 1976, surveillance activities were mainly concentrated in the upper and middle zones, including seven urban areas where a house-to-house search for cases was organised together with a facial pockmark and vaccination scar survey. Weekly markets were visited periodically and outbreaks of fever and rash were investigated. At the end of 1976 and the beginning of 1977, surveillance activities were concentrated in the lower zone, bordering India. A thorough house-to-house search, covering all villages and municipalities, was organized and a facial pock mark and vaccination scar survey was carried out. Fever and rash rumours were collected and subsequently verified by experienced field workers. A WHO International Commission confirmed on 22 April 1977 that smallpox had been eradicated in Bhutan. ⁶

There is nothing unusual about the brevity and blandness of this analysis. The tone was almost replicated in the multi-authored, widely celebrated official history titled Smallpox and its Eradication published by the WHO HQ in 1988. Numbering all of 1460 pages, it devoted about four paragraphs and a few stray sentences to Bhutan, largely placed in a concise section that also discussed the situation prevalent within the kingdom of Nepal and the Indian protectorate of Sikkim (the latter became a formal part of the Republic of India in 1975). The potted history of the Bhutanese programme provided by the following paragraph gives us an effective appreciation of the limited scope of this retrospective official analysis:

Until 1961, no health department had been established in the country. In 1964, the government created 19 posts for vaccinators, and increased the number to 25 in 1966, when a mass vaccination campaign was begun following an outbreak of 74 cases of smallpox in 1965–1966 in the capital city of Thimbu [sic]. The outbreak had begun among Indian and Nepalese workers employed in a road-building project and then spread to the local population. The number of vaccinations reported to have been performed between 1967 and 1975, however, was small in relation to the population of 987,000 (1967 estimate). After the 1965–1966 outbreak, only 4 further outbreaks were reported. In 1967, 2 outbreaks originating in Assam caused 14 cases. The third outbreak, of 6 cases, occurred in April 1973 in a village near the south-western border with India, the initial case having been infected on a tea estate in West Bengal. The fourth outbreak, near the same border area, occurred in February 1974 and consisted of 3 cases, of which the first had been infected in Assam. Surveys conducted in 1976 to detect individuals with facial pockmarks, as well as interviews with village officials, indicate that other, unreported outbreaks had occurred although none had produced more than a few cases. This was attributed in part to the fact that the villages were scattered and isolated, and in part to the sensible traditional practice of isolating the patient and his family at the onset of illness in a place some distance away from the village. In these circumstances, the spread of smallpox was difficult. ⁷

These official narratives provide the strongest possible justification for the preparation of an alternative, more complex analysis of the Bhutan national smallpox eradication campaigns and the many ways in which they were linked to the worldwide programme targeting variola. The most effective means of doing this is by using a range of unpublished documentation that has been stored away in the recesses of the WHO archives in Geneva, a large proportion of which has not been assessed critically before; these papers are important because they allow us to focus on debates and discussions that were largely carried on away from the public gaze. For our purposes here, it is useful to analyse an expansive set of conversations involving a variety of actors: the smallpox eradication unit within the WHO HQ in Geneva, a group of well-connected medical volunteers based in the USA, the royal court and government of Bhutan in Thimpu, the WHO SEARO offices in New Delhi and, not least, the Indian federal authorities and their representatives in the Himalayan kingdom.