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REFLECTIONS ON THE ERADICATION OF SMALLPOX

Friday, 31st of July 2015

REFLECTIONS ON THE ERADICATION OF SMALLPOX

Sanjoy Bhattacharya

Also at http://dx.doi.org/10.1016/S0140-6736(10)60692-7

A momentous act, regarded as impossible by many, occurred in May, 1980. The World Health Assembly, hosted by WHO in Geneva, certified that smallpox had been eradicated globally. The end of a damaging disease was celebrated in many medical, political, and scientific quarters; it was a recognition of the fact that future generations were now free of the pain, death, and mutilation that variola had inflicted in the past.

The resulting optimism had far-reaching effects, and helped foster several health-care projects during the 1980s. The Expanded Programme on Immunization (EPI) was a major beneficiary and a strong case could be made within WHOs complex frameworks for the organised deployment of immunisation campaigns. This was remarkable considering that powerful elements within WHO, including Halfdan Mahler, the Director General between 1973 and 1987, were pushing for the development of competing schemes of primary health care. It was a testament to the power of a widespread acknowledgment that the natural existence of a dangerous infectious disease had been purged by a series of human interventions.

Sanjoy Bhattacharya

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It would be simplistic to reduce the worldwide smallpox eradication programme to the ideas and actions of a handful of individuals or, indeed, the institutions to which they were associated. There can be little doubt that agencies such as Fiocruz (Brazil) had an important role in Latin America, that the US Centers for Disease Control and Prevention made pioneering contributions within western Africa, and that WHO headquarters in Geneva helped mobilise people and resources across the then politically unstable south Asian subcontinent. It is also beyond doubt that all these institutions went on to play key roles in advising colleagues, funding initiatives, and contributing personnel and vaccines on an international scale. However, this should not lead us to assume that their employees were unquestioning instruments in the implementation of a finite set of ideas developed by a select leadership. To the contrary, the enormity of the success of global smallpox eradication can only be appreciated when one acknowledges the continued presence of variations in training, attitude, ability, and commitment in groups involved in vaccination, smallpox searches, and disease isolation regimes.

Some determinants of this success were deeply personal in nature and were connected to beliefs about religious, political, social, and institutional obligations; other stimuli were external, in the sense that they took the form of myriad political, social, economic, and cultural challenges presented from within the localities where work was undertaken. The attitudes and work of personnel for smallpox eradication programmes were not divorced from such wide-ranging stimuli; they were influenced by an ever-changing combination of factors. This, in turn, fostered ways of designing, applying, and evaluating policy, which contributed to the creation of an intricate mosaic of operational diversities.

As the 30th anniversary of the certification of global smallpox eradication nears, it is no surprise to witness organised efforts on the part of government and non-government agencies to highlight their contributions to this memorable triumph. The danger, of course, is that these exercises will chronicle relatively few voices and then present them as being representative of the “reality” of the eradication programme as a whole; such an approach is to be avoided, although these individual voices are, of course, valuable. The global project to limit the spread of variola, as it evolved in the 1960s and 1970s, involved countless participants. It was simultaneously an international and local entity, and each avatar had several constituents. The first included donor nations and multilateral health agencies such as WHO. But the global smallpox eradication programme also involved federal and provincial governments, as well as members of elected local authorities who remained answerable to a variety of urban and rural electorates. Ground realities were complicated further by the fact that the day-to-day running of the national chapters of the global programme remained largely dependent on the efforts of workers drawn from within the countries themselves. Local personnel were involved in house-to-house searches, and also served as team leaders, translators, vaccinators, supervisors, and guards of lodgings where smallpox cases were being isolated. Such local participation was not just enforced by shortages of international staff; it was actively encouraged in the 1970s by senior programme managers situated within WHO offices in Geneva and New Delhi.

At one level, this inclusiveness was a formal recognition of the fact that the task at hand was far too large for a small group of international workers. In other ways, field experience taught managers that local political and infrastructural conditions deserved careful study to help avoid problems, assist in effective negotiations with the target population, and allow for the meaningful adaptation of policy as and when it was necessary. Such strategies, although time-consuming, enabled the mobilisation of support from among civilian communities. Based on the willingness of workers to spend long stints of time on the road, this policy revolved around winning trust locally; mobile teams were often required to spend time in villages and towns, making an effort to get to know members of local administrative bodies and community representatives. Social engagements, in the form of participation in grand village feasts or discussions over more private meals, frequently formed important points of interaction and negotiation. These communication strategies contributed to a scenario where the use of forcible vaccination remained a fairly rare phenomenon in most national contexts.

Force was, of course, sometimes used to achieve immunisation targets, as some important commentaries have noted. Organised and violent resistance during epidemics could provoke ferocious responses from vaccination teams, especially as the successful eradication of smallpox began to seem a possibility in the mid-1970s. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. It is, at the same time, important to remember that the use of force and that the clashes it stoked were mostly isolated incidents. Compulsory vaccination schemes were planned and implemented with the assistance of national and local administrative structures, including the police and paramilitary forces at their disposal, which had considerable societal support. All countries in the world are characterised by the presence of complex social formations, and it is thus imperative that chroniclers of smallpox eradication avoid describing national and local societies as monolithic entities that responded in uniform ways. National contributions to the global smallpox eradication programme had many facets. The planned use of compulsion in vaccination programmes, and the resultant social and political backlash, which varied in intensity across nations and their locales, was one of them. Considered reflection about these trends, and the many factors that influenced them, such as deep-rooted concerns about vaccine safety, can allow for the presentation of a more rounded picture of global smallpox eradication. This exercise is pertinent precisely because descriptions of episodes involving official force and social resistance are frequently downplayed in tomes seeking to celebrate the contributions of individuals, public health institutions, and national governments.

Broad-ranging assessments of the intricacies of the global smallpox eradication programme can also offer other insights. They can, for instance, allow us to query simplistic understandings of vaccination strategies used in the 1970s, including explication relating to the holy grail of search and containment policies. The importance of the decision to direct field work on the identification and isolation of smallpox cases and the vaccination of contacts is undeniable; this was a revolutionary concept borne out of the necessity of working with finite vaccine stocks. It is also true that the approach was trialled by groups of young American workers in western Africa in the late 1960s and then adopted elsewhere by wider constituencies. However, it would be incorrect to assume that the transfer of such practical information was unidirectional, universal, and uncontested. Search, containment, and vaccination work was actually also tested in 1967–68 in Madras, India, with the active encouragement of WHO officials. Reports about the success of these field trials were widely distributed and encouraged some, but not all, Indian administrators to embrace the new strategy. This is, perhaps, not surprising. In an age marked by cold war hostilities, hypernationalism, and widespread conflict, the origin of a policy or a set of practices was important to questions about implementation and reception. This also helps explain why the older practice of mass vaccination was continued across large tracts of south Asia well into the late 1970s. This approach was often preferred by groups of local and international workers, and was sometimes a response to demands emanating from within the target community. Indeed, mobile teams were often faced with requests to vaccinate everyone in the village and it was generally considered expedient to accept such requests. It is important to keep all these trends in mind, lest the ideas, actions, and contributions of large numbers of people—and the sheer complexity of field practice—is forgotten as the celebrations connected to the continued absence of smallpox start in earnest.

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