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UNCERTAIN ADVANCES: A REVIEW OF THE FINAL PHASES OF THE SMALLPOX ERADICATION PROGRAM IN INDIA, 1960-1980

Friday, 31st of July 2015

UNCERTAIN ADVANCES: A REVIEW OF THE FINAL PHASES OF THE SMALLPOX ERADICATION PROGRAM IN INDIA, 1960–1980

Sanjoy Bhattacharya, PhD

Am J Public Health. 2004 November; 94(11): 1875–1883.

A Review of the Final Phases of the Smallpox Eradication Program in India, 1960–1980

The author is with the Wellcome Trust Centre for the History of Medicine at University College London, England.

Requests for reprints should be sent to Sanjoy Bhattacharya, PhD, The Wellcome Trust Centre for the History of Medicine, University College London, 24 Eversholt St, London NW1 1AD, England (e-mail: ku.ca.lcu@ayrahcattahb.yojnas).

© American Journal of Public Health 2004

Best viewed, with table, at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448554/

Abstract

In this article, I describe the complex nature of the final phases of the Indian smallpox eradication program. I examine the unfolding of policies at different levels of administration and the roles played by a wide range of national and international actors. A careful examination of unpublished official correspondence, on which this article is largely based, shows that the programs managers were divided and that this division determined the timing of the achievement of eradication. This material also reveals that Indian health workers and bureaucrats were far more capable of reshaping policies in specific localities, often in response to local infrastructural and political concerns, than has been acknowledged in the historiography.

THE ERADICATION OF SMALLPOX in India would not have been possible but for the contributions of many actors. The headquarters of the World Health Organization (WHO) in Geneva, Switzerland, and its South East Asia Regional Office, based in New Delhi, India, played a prominent role. So did the health ministries of the Indian central and state governments. All of these agencies set up a series of special “eradication units,” which deployed several energetic medical and public health personnel all over the subcontinent. The Soviet Union, the United States, Sweden, and a host of other Asian and European countries provided generous doses of aid, often bilaterally (without involving intermediary non-governmental agencies), in the form of field operatives, vaccine, operating kits, and money. Indian and international charitable institutions made significant contributions at crucial junctures as well.1

The involvement of such a great variety of workers is not surprising considering how complicated the organization of the final stages of the Indian smallpox eradication campaign turned out to be. The country was huge, with stretches of very difficult terrain, often with no access to transportation links. The topography was varied, and specific campaign methods had to be organized for each territorial context. Language and culture were equally varied. More than 20 major languages and several local dialects were spoken, and there was a wide variety of religious traditions and class configurations in the localities of each Indian state. The administrative challenges did not end there. Many sections of the Indian population were often not only uncooperative but also openly hostile to the quest for smallpox eradication.

Even though commentaries about smallpox eradication in India have frequently disagreed about the value of the contributions of particular players, a uniformly celebratory element is particularly noticeable in publicity documents, official histories, and memoirs. These generally also present a simplified picture of a unified campaign workforce, supposedly confident about its goals and consistently effective in the field owing to its educational and technical expertise. A prime example of this is provided in the foreword written by Donald Henderson, the inspirational chief of the special Smallpox Eradication Unit set up within WHO headquarters in Geneva, in the organizations official history of the eradication program. As Henderson writes,

One of the most gratifying features of this programme is the unified and effective way in which the Government of India and the World Health Organization have collaborated. At every level national and WHO staff worked shoulder to shoulder, pursuing their goal with technical competence, dedication and enthusiasm.2

Perhaps unsurprisingly, unpublished WHO and Government of India correspondence reveals a far more complex picture. Agencies sponsored by WHO and the Indian government were often at loggerheads on matters of strategy in particular situations, which shows that neither administrative organization was monolithic in nature. Moreover, many officials, of different nationalities and ranks, remained skeptical about the possibility of expunging variola from the subcontinent. This group even included some of the campaigns staunchest supporters within WHO, who often privately questioned many of the successes claimed regarding the dramatic reduction of the diseases incidence in the early 1970s.

Despite their ability to provide a more nuanced understanding of the final chapters of one of the most important international health programs of the 20th century, these administrative complexities are often ignored.3 In this article, I attempt to show why it would be profitable not to do so.

CREATION OF THE INFRASTRUCTURE FOR ERADICATION

The WHO Health Assembly repeated calls in the 1950s for smallpox eradication caused international attention to be focused at India, as it was a major reservoir of the disease (Table 1 ▶). This critical gaze made several senior members of Indias central government, including Jawaharlal Nehru, the prime minister, uneasy. The widespread incidence of variola was considered by this modernizing crusader, with his keen sense of how India was perceived on the international stage, as a stigma; it was a sign that his regimes agenda of rapid reform and development was unfolding less effectively than planned.4 Since the prime minister was the chief executive authority in the country (the Indian president, who was elected by the 2 houses of parliament, was merely a figurehead), Nehrus views ensured action from the federal Ministry of Health. A so-called “Central Expert Committee” was appointed in May 1958; it was asked to put forward proposals about the best means of eradicating variola.

Smallpox Cases in India and the World, 1950–1977

In many ways, however, this was a limited exercise—setting up a committee was one thing, getting policies enacted and bureaucratic and civilian support was quite another. Prime ministerial authority was relatively slight at this time, when state-level politicians and bureaucrats were allowed significant levels of autonomy. In addition, there was political hostility to the proposal for an organized smallpox eradication program. Even Nehru, widely regarded as a charming negotiator with a knack for rallying wide-ranging political support on the domestic front, found it difficult to get rid of opposition from senior bureaucrats within the federal and state-level health ministries, which were reported as being deeply divided about the issue.5

Senior WHO officials in Geneva were well aware of these administrative divisions at each level of Indian government. Nevertheless, they developed plans for smallpox eradication in India, assuming that bureaucratic and political opposition in the country would ultimately be overcome with the support of senior members of the central government. This assessment was powerfully underlined by the presentation of a Smallpox Eradication Criterion in August 1961.6 Strikingly, this prescription proved unpopular within the headquarters of the WHOs South East Asia Regional Office, based in New Delhi, the Indian capital. These WHO workers, therefore, demanded changes in the statement released from Geneva, arguing that this was necessary in view of the local administrative and political situation.7 Although this reminder of organizational disunity irritated the WHO headquarters, its officials were forced, nevertheless, to provide a written reassurance to New Delhi that local epidemiological and infrastructural factors would be considered during the planning and running of an Indian eradication program.8

The wisdom of developing regionally relevant policy was underlined quickly. Even as pilot smallpox eradication schemes were started in 1 district of each of the 22 Indian states in 1960, the damaging effects of local infrastructural constraints and bureaucratic lack of interest became obvious. The deployment of all the pilot projects, which were intended to introduce a 100% vaccinal coverage, was delayed everywhere, causing much-publicized WHO and central targets to be missed. Worryingly for the Federal Health Ministry, these setbacks appeared as other disease eradication and control programs began to hit stormy waters and their managers started demanding greater chunks of central government allocations (the flagging national malaria eradication program was a good case in point, as was the troubled drive for tuberculosis control).9

These difficulties ensured that the structures supporting the national smallpox eradication program developed far more slowly than many WHO officials had hoped. The initial burst of growth was limited to the development of a new central nodal organization based in New Delhi, which was accompanied by a round of reform of local administrative rules seeking to make state-level public health officials more answerable to their superiors in New Delhi.10 Nevertheless, smallpox eradication work in the states was dogged by delays, and this situation was justified by persistent references to financial difficulties.11

While central government financial assistance allowed the completion of most of the state-level pilot schemes, several senior central government observers were disheartened by the administrative difficulties that had been thrown up in almost every context. Indeed, unpublished correspondence from the second half of the 1960s shows that many powerful administrators considered these difficulties to be proof that expunging variola was impossible, and they began to develop plans for cutting back the national smallpox eradication program budget.

News of these developments set alarm bells ringing throughout WHO, causing Donald Henderson to personally approach the director general of Indian Health Services in February 1967. His aim, which seems to have had widespread support in Geneva, was to ensure that the Indian government continued to back the eradication goal, albeit on a new basis. Henderson suggested that all aspects of the sub-continental campaign be thoroughly reformed. These changes were not only to involve governmental structures but also to include the relevant departments of WHOs South East Asia Regional Office; senior WHO representatives seemed to consider it politic to accept part of the blame for the problems that were continuing to hound smallpox immunization work in India.12

Hendersons intervention was apparently timely, even though he appears to have been uncertain initially about the effectiveness of his efforts and of WHO headquarters public declarations of support for the Indian government.13 One of his letters to the American Embassy in New Delhi reported, for instance, that the Indian administrators were giving mixed messages and that Geneva had no clear idea whether the subcontinental campaign would survive the year.14 He need not have worried. The promises of additional aid caused the Indian federal authorities to reconsider their plans of scaling back their antismall-pox measures and led to what was widely regarded as a helpful reshuffle of bureaucrats within the central health ministry department charged with responsibility for coordinating the eradication program.15

PROGRAM EXPANSION, REORGANIZATION, AND REDEPLOYMENT

The developments of 1967 brought about a major shift in the organization of the subcontinental smallpox eradication program. This shift was not, however, just a result of the WHO decision to embark on a worldwide campaign of mass immunization. The changes initiated in Geneva and New Delhi from April onward were a direct response to the Indian governments threat to withdraw support. These changes brought heightened levels of WHO assistance. The organizations willingness to commit extra resources did, of course, have certain advantages for the managers of its smallpox eradication units—they were able to extract the Indian prime ministers permission to launch a mass immunization drive in the subcontinent, with both sides agreeing that this work would be conducted in collaboration with Federal Health Ministry officials. The new plans of action were, therefore, a result of the coming together of the strategic needs of both parties.

The WHO headquarters attempted to kick-start the goal of achieving countrywide mass vaccination by employing large numbers of foreign workers; by agreement with the Indian central government, they were expected to work with the local bureaucrats. Geneva also arranged for the reorganization of the smallpox eradication unit attached to the South East Asia Regional Office. Once again, this was achieved by the involvement of numerous foreign workers, on a variety of short-term contracts, who had experience in managing public health projects. However, a variety of problems cropped up. It was difficult to find sufficient numbers of foreign staff; Henderson found it hard to convince the US government and universities to provide experienced consultants at this time.16 Additionally, the WHO offices in Geneva and New Delhi had to get the international workers cleared by the Indian authorities, which was not easily achieved. Reports frequently referred to friction between short-term WHO consultants, officials working on long-term contracts for the South East Asia Regional Office, and Indian bureaucrats.17

All these problems combined to reduce the effectiveness of the mass vaccination drives launched in 1968; the continuing shortages of efficacious freeze-dried vaccine and operating gear did not help either. As a result, despite what the Indian government described as “gigantic and concentrated” efforts to reformulate immunization policy between 1968 and 1970, the incidence of smallpox remained high. These circumstances exacerbated tensions between the eradication units run by WHO and the Indian Health Ministry, as officials blamed each others tactics. Henderson, for instance, referred to the problems existing between the “various warring factions within the Ministry and between the Ministry and the States.”18

At another level, though, the high incidence of variola encouraged the formation of new alliances. This process involved workers and bureaucrats who supported a shift from the goal of mass vaccination to a new strategy of “surveillance–containment,” based on the isolation of infected people and selective vaccination of smallpox-stricken communities and “rings” of contacts (immediate contacts targeted first, after which the scope of vaccination increased to cover a broader range of potential contacts).19 These views did not go unchallenged. Reports frequently mentioned how variola outbreaks in the districts could throw carefully laid plans for surveillance–containment out of gear in a situation where local bureaucrats frequently reverted to the strategy of mass vaccination.20

In the light of such administrative challenges, the managers of WHOs smallpox eradication units in Geneva and Delhi made concerted efforts to gain the Indian central governments help in bringing hostile members of the federal and state health ministries and local bureaucrats into line. While published reports and official accounts of the eradication campaign are mostly silent about this tactical shift, unpublished correspondence reveals how important it was considered by a range of senior WHO officials. It was not enough to have the stated support of the central authorities; it was now recognized that it was important formally to involve the federal government in mobilizing local political and bureaucratic support.

This strategy of using central government assistance to bring state employees into line was neither easy nor always successful. Such high-level political support was inconsistent and needed periodic renewal. The genius of Henderson and of Nicole Grasset—an inspirational French official employed by the WHO South East Asia Regional Office headquarters—lay in their ability to make this support possible through lobbying exercises, which were at times based on the unconventional tactic of approaching Indira Gandhi, the powerful Indian prime minister, directly, sometimes in violation of diplomatic protocols. Gandhis support was significant, as she was actively involved in centralizing power and was in a position to force relatively compliant state chief ministers to support, at least publicly, specific immunization campaigns.21

A good instance of this strategy occurred in 1972, a year considered crucial by WHO and the federal government, which believed that a concerted search of certain states was then necessary if eradication was to be achieved in India.22 Central government cooperation, stoked by support from the prime ministers office, caused so-called “smallpox endemic states” such as Jammu and Kashmir and Bihar to be searched intensively.23 As a direct result, thorough surveillance–containment efforts, more rigorous than at any time in the past, were launched. Work was often conducted on a systematic, door-to-door basis, particularly in areas where smallpox outbreaks were confirmed. The policy was effective, and even the most demanding assessments accepted that by late 1972, smallpox was endemic only in the 4 contiguous states of Bihar, Uttar Pradesh, West Bengal, and Madhya Pradesh.24

REORGANIZATION AND REDEPLOYMENT

This success in limiting the scope of variola in India surprised many within both WHO and the Indian government, and questions were raised by those hostile to the eradication program about the reliability of the data being presented. Nevertheless, this reduction in the area of smallpox endemicity was seen as a major advance, so much so that WHO began negotiations for the launch of an even more concentrated program of action, targeted primarily at the remaining pockets of variola. On the basis of an offer of even greater levels of financial and infrastructural assistance, these deliberations were successful, and the so-called intensified smallpox eradication program was launched in 1973. Grasset and Henderson played an important role in negotiations with international financial donors; special funds were, for instance, made available by the Swedish International Development Agency after considerable efforts on their part.25

Despite the deployment of unprecedented levels of financial and technical resources, difficulties in running the intensified program began to show up almost immediately. Reports of numerous cases of bureaucratic opposition in the states, districts, and subdivisions threatened to sour the spirit of cooperation that appears to have developed among at least some senior WHO and Indian government officials. Faced with recurrent smallpox outbreaks across eastern India, accusations of inefficiency, impropriety, and lack of commitment began to be traded in meetings and correspondence.26 Grasset felt, for example, that problems were being created by officials at the level of state governments. She accused their officials of playing a double game, publicly promising help to the smallpox eradication departments of the Federal Health Ministry and WHO but remaining noncommittal in private.27 Senior WHO officials, therefore, began to push the Indian government, from 1974 onward, to convert the intensified program into a centrally controlled campaign, one that was politically supported by the prime ministers office and run by the Federal Health Ministrys smallpox eradication department.28

Yet this aim was not easily achieved in a situation in which the Indian prime ministers support fluctuated over time for reasons that are impossible to identify definitively. The important point, though, is that her commitment to the eradication goal varied, which kept senior WHO and Indian government officials supportive of smallpox eradication on the defensive. Indira Gandhi would sometimes fully endorse the aims of campaign, release statements to that effect, and allow the WHO officials to distribute copies of these during their tours in the states.29 She would also sometimes force senior state officials—the chief ministers and health ministers—to show similar levels of support.30

On other occasions, however, this encouragement appeared to all but evaporate. At one point, for instance, the federal health minister was permitted, almost at a whim, to freeze the number of international staff members WHO could deploy. The pressures imposed on state-level workers to cooperate with WHO teams were often relaxed at such times; the hostility of several senior health ministry officials to colleagues working within the smallpox eradication department, which had close links with Grassets and Hendersons offices, also contributed to these trends. Such patterns of inaction and hostility could prove to be administratively problematic. Apart from allowing the underreporting of variola cases, it created a situation in which surveillance–containment operations were mishandled—local workers would often carry out mass vaccinations over an area of only a 5-mile radius, without any attention given to people at high risk of infection. Workers often failed to detect people who were away from home and possibly carrying smallpox between villages. And district officials seeking to justify their inability to meet vaccination targets frequently exaggerated vaccination refusal rates.31

Thus, when around the middle of 1974 the Indian government accepted the proposal that the running of the intensified program be fully centralized, the move was widely celebrated within the WHO offices in Geneva and New Delhi, not the least because it formally offered their smallpox eradication units the option of working in an organized manner with the Federal Health Ministry. The officials attached to these agencies were now going to be allowed access to a centralized fund, built up with contributions from a range of donors and held in Geneva. These developments also allowed the creation of a new, well-organized program bureaucracy that was distinct from the workforce attached to other disease control programs run by the federal and state health ministries. This bureaucracy was to be varied in composition, based not only on workers from the United States, western and eastern Europe, and Asia (the US Centers for Disease Control [CDC] and the Soviet Academy of Sciences contributed several consultants to WHO) but also on the employment of local bureaucrats, Indian private medical practitioners, and medical students from subcontinent colleges, who were placed on a variety of short-term contracts.32

Increased financial and infrastructural input did not automatically translate into success. The centrally controlled intensified smallpox eradication program was not always able to attract the support of local administrative networks and operate without impediment. The special status accorded to the campaign and its workforce often made it deeply unpopular among sections of the Indian central and state governments. This antipathy even included elements within the Federal Health Ministry, who continued to undermine the intensified program. A dramatic example was Dr J. B. Shrivastav, the director general of health services and the senior-most bureaucrat within the Federal Health Ministry. Dr Mahendra Dutta, a senior member of the ministrys smallpox eradication department, noted that Shrivastav began to question the surveillance–containment policy at a time that it was considered crucial. Presenting himself as a supporter of the policy of 100% vaccinal coverage, he began distributing warnings about the dangers arising from the development of a “vaccination backlog.” This created doubts among more junior state-and district-level officials, who began to worry about what would happen to their career prospects if they were found to be ignoring the views of Shrivastav and his allies. As a result, they often tended to be less than cooperative with the smallpox eradication teams.33

The problems did not end there. At the same time, certain state administrators began to demand that workers attached to other vertical public health programs and health centers return to their original duties, rather than buttress the intensified program. Indeed, WHO officials soon found themselves competing for resources with family planning schemes launched by the central and state health ministries owing to pressures imposed by Sanjay Gandhi, the prime ministers politically powerful son.34 Senior WHO officials such as Grasset and Henderson tried to lighten the impact of these developments by directing diplomatic initiatives at the prime ministers office, the state chief ministers, and the federal and state health ministries. However, only some of these efforts proved successful; the intensified eradication program moved ahead in fits and starts during the course of 1974.35

Nevertheless, efforts at strengthening the program continued apace right through 1975. These took several forms: more foreign consultants were brought in from a variety of countries, greater numbers of local workers were contracted on a temporary basis with funds held at WHO headquarters, and the support of senior politicians and bureaucrats was lobbied continuously. These efforts paid off; eastern India was systematically and intensively searched for variola pockets, leading to the discovery of several cases in January of that year. While the month had started off well, with less than 100 outbreaks being reported throughout the country in the first 2 weeks, a search carried out by a team led by Dr R. B. Arnold, a CDC epidemiologist posted in Nalanda, in the state of Bihar, revealed a large cluster of new cases at Pawa Puri village. The situation was complicated by the fact that several hundred Jain pilgrims—a religious community averse to vaccination—were visiting the village on a daily basis.36

A USEFUL EPIDEMIC

Ironically, however, this outbreak proved useful to the program managers. Reference to the crisis allowed them to reinvigorate support for eradication, as several senior politicians and bureaucrats were reminded that the battle against variola was far from won. This event also allowed Grasset and Henderson, and their allies within the Federal Health Ministry, to get the prime ministers ear: Gandhi did not want her regime to be identified with the failure of a global program. Her office began involving itself in bringing into line the state ministries run by the ruling Congress Party.

The benefits of such trends were clearly visible in the weeks following the Bihar outbreak. Even though several ministerial employees and civil servants doubted that variola could be expunged in the subcontinent, Gandhis firm intervention ensured that they were forced to support efforts to contain the outbreak and carry out detailed searches of surrounding areas. In this regard, the role played by Sharan Singh, Bihars chief secretary, was important. He kept pressuring branches of the state administration and the chief minister and helped ensure the deployment of governmental resources for special epidemiological teams, which were set up in association with the smallpox eradication unit in New Delhi. Singh also negotiated a political arrangement whereby Dr Larry Brilliant, an American consultant employed by WHOs South East Asia Regional Office, was allowed to take over responsibility for coordinating activity in Pawa Puri. The central government even cleared the Bihar Military Police to assist these special epidemiological teams; military personnel helped cordon off affected villages and provided protection to program staff.37

Notably, the managers of the intensified program kept reminding the central and state governments, as well as national and international funding agencies, about the possibility of another serious smallpox outbreak if their work slackened. The dangers arising from such potential crises were also underlined; India, it was frequently pointed out, could very well end up bearing the stigma of causing the failure of a high-profile global eradication campaign. By all indications, these tactics were effective. Funding bodies, such as the Tata Industrial Group and the Swedish International Development Agency, renewed their financial commitment. Surveillance–containment measures elsewhere were retained as well, generally with active assistance from the Government of India, which allowed its antimalaria and family planning units to be used frequently by the managers of the smallpox eradication program, most notably to strengthen search activities in eastern and northeastern parts of the country.38

Announcement of the so-called “smallpox zero status” followed soon after; the last indigenous case was reported on May 17, 1975, from the Katihar district of Bihar.39 The news was announced officially by Dr Karan Singh, the federal minister of health, on June 30, 1975, and was then widely publicized. The achievement was also celebrated through a variety of public functions, some coinciding with the countrys independence day celebrations on August 15, 1975. Even though the managers of the intensified program participated in these celebrations, privately they were uncertain about the wisdom of announcing such a “victory.”40 Henderson and Grasset highlighted the need to push through the message that the eradication of smallpox in India could by no means be taken as guaranteed.41 A great deal of effort was therefore expended by WHO and the smallpox eradication department of the Federal Health Ministry, which advertised the importance of continuing detailed countrywide searches through 1976 and 1977.

These efforts paid off, but despite Indira Gandhis enthusiasm for this final drive, the Indian administrative services were by no means united in their support for the retention of an intensified program. Even at this late stage, when a victory against variola in India had been confidently announced by the federal authorities, many officials in New Delhi and the states believed that variolas disappearance was temporary and that it would inevitably reappear, after being reintroduced from Bangladesh or Africa.42 Program workers of all ranks worried incessantly about unearthing a large pocket of smallpox. This anxiety caused generous monetary rewards to be offered for the notification of variola cases, with detailed investigation of all resultant reports.43

As it transpired, these fears proved misplaced. Managers of the intensified program were able to start preparing the documentation that was to certify the eradication of smallpox in India by September 1976.44 This evidence was cross-checked by an independent team of international workers over the course of several months, and India was certified smallpox free on April 23, 1977.

CONCLUSION

The successful outcome of the smallpox eradication program demanded persistent hard work by a range of Indian and international officials. The personal sacrifices were often great: program officials were forced to spend protracted periods of time away from their families in unfamiliar contexts and experienced demanding shifts in the field that often led to physical exhaustion and ill health. This work was frequently a thankless task, as workers encountered the hostility not only of those they were seeking to protect from a dreadful disease but also of politicians and officials. As a result, their experience was often bittersweet: sometimes extremely frustrating but also greatly gratifying, especially when certification of eradication was achieved against overwhelming odds.45

A detailed examination of the experiences of these workers and of their interactions with different governmental departments and officials thus presents a nuanced picture of the multi-faceted smallpox eradication program. This program is sometimes simplistically presented as a vertically organized campaign that was imposed on India by powerful industrialized nations. If anything, Indian administrators accepted the launch of an organized effort aimed at expunging variola on their own terms; the campaign was also run on their terms over several years, despite the best efforts of certain WHO officials to dictate the design and unfolding of policy in the subcontinent.

These trends were visible at all levels of administration. The prime minister, the Federal Health Ministry, and the central government bureaucracy reminded WHO representatives of their autonomy at every available opportunity. As a result, WHO was forced to change its strategic plans for smallpox eradication in the subcontinent and agreed to contribute generously to the setting up of a special bureaucracy for the purpose. And yet, this administrative flexibility did not solve all their problems. State- and district-level administrators, keen to demonstrate their unwillingness to be ordered about by international and New Delhi–based officers, also provided differing levels of cooperation to the plans put forward by the smallpox eradication units. As a result, senior WHO officials remained acutely aware that none of their goals would be met without political and bureaucratic assistance from the highest levels of the Indian government. It was recognized that such support was most likely to arise from supplicatory requests made through diplomatic initiatives.

It is also noteworthy that the smallpox eradication program had variable effects on the running of the health delivery systems based at the different levels of the Indian administration. While it is undeniable that some dispensary facilities were affected adversely by the eradication drive, as health personnel were drawn away from their daily responsibilities, this situation was by no means common. In fact, accusations that the smallpox eradication program harmed the provision of local health care facilities were frequently exaggerated and politically motivated. Apart from representing the annoyance of bureaucrats and politicians doubting the possibility of eradicating variola, these criticisms were often used to obscure the fact that many subdivisional health care facilities were not as comprehensive as state government officials had claimed in their reports, publicity materials, and election speeches.

The smallpox eradication program thus appears to have competed far more vigorously for financial resources than other centrally administered vertical health schemes, such as family planning campaigns. It is also worth noting that the managers of the smallpox eradication program considered it useful to employ members of local communities on short-term contracts for special antiepidemic measures and state-level intensive surveillance–containment campaigns. These short-term employees were seen as an invaluable source of locally pertinent information, as well as being useful for introducing teams of touring officials to the rural communities being targeted. They were also asked to report on the effective working of local medical and public health officials, who were expected to report all rash and fever cases they encountered during the course of their routine duties for further investigation.

To conclude, it is impossible to tell the complete story of a complex public health program like the smallpox eradication campaign through published WHO and Indian government reports and through the celebratory official histories and memoirs of field workers. Such commentaries usually tend to present an oversimplified sense of unity of purpose, overemphasize the contributions of certain organizations and individuals, and downplay many of the serious problems bedeviling the campaign. A careful analysis of unpublished correspondence, conversely, shows us how policies developed at the level of the WHO headquarters and the Indian central government had to be readapted continuously to meet local conditions. It also reveals that a range of workers, of different nationalities and with widely varying professional qualifications, were responsible for a monumental triumph that many had thought impossible.

Acknowledgments

The research for this article was supported by the Wellcome Trust and the Wellcome Trust Centre for the History of Medicine at University College London. I am grateful to Ted Brown, Hal Cook, and Sangeeta Chawla for their editorial suggestions.

Endnotes

1. The World Health Organizations (WHOs) official history of the last phase of the smallpox eradication program provides a detailed list of the international and Indian epidemiologists deployed in the subcontinent. See R. N. Basu, Z. Jezek, and N. A. Ward, The Eradication of Smallpox From India (New Delhi: WHO/South East Asia Regional Office, 1979).

2. Ibid.

3. The result is the presentation of huge generalizations about the structures and goals of WHO and the smallpox eradication bureaucracy it helped set up. See, for instance, footnote 21 in H. Naraindas, “Care, Welfare, and Treason: The Advent of Vaccination in the 19th Century,” Contributions to Indian Sociology (new series) 32 (1998): 94.

4. See, for instance, speech by Jawaharlal Nehru about the importance of smallpox eradication reproduced in the National Smallpox Eradication Programme in India (New Delhi: Ministry of Health and Family Planning, Government of India, 1966), 1.

5. Report of the Smallpox Workers Conference (18–20 February 1964) (New Delhi: Ministry of Health, 1964), 25.

6. Memorandum from Dr W. Bonne, director, Communicable Diseases Section, WHO Headquarters, Geneva, to Dr C. Mani, regional director, South East Asia Regional Office, New Delhi, India [hereafter SEARO], August 8, 1961, File SPX-1, Box 545, Smallpox Eradication Archives, World Health Organization, Geneva, Switzerland [hereafter WHO/SEP].

7. Memorandum from regional director, SEARO, New Delhi, to the director, Communicable Diseases Section, WHO Headquarters, Geneva, August 18, 1961, File SPX-1, Box 545, WHO/SEP.

8. Memorandum from Dr W. Bonne, director, Communicable Diseases Section, WHO Headquarters, Geneva, to Dr C. Mani, regional director, SEARO, September 14, 1961, File SPX-1, Box 545, WHO/SEP.

9. See, for instance, Report 1961–62: Ministry of Health, Government of India (Delhi, 1964), 3, Shastri Bhavan Library, New Delhi, India [hereafter SBL].

10. See, for instance, circular letter from deputy secretary, Ministry of Health and Family Planning, Government of India [hereafter GOI], to public health departments of all state governments, January 3, 1962, reproduced in National Smallpox Eradication Programme in India, 20–23.

11. Report 1961–62: Ministry of Health, 19.

12. Letter from Henderson D. A., chief, Smallpox Eradication, WHO Headquarters, Geneva, to Dr K. M. Lal, GOI, February 21, 1967, File 416, Box 193, WHO/SEP.

13. See, for instance, telegram from A. M. H Payne, WHO Headquarters, Geneva, to the regional director, SEARO, April 4, 1967, File 416, Box 193, WHO/SEP.

14. Letter from Henderson D. A., chief, Smallpox Eradication, WHO Headquarters, Geneva, to Dr E. S. Tierkel, USAID Office, American Embassy, New Delhi, April 12, 1967, File 416, Box 193, WHO/SEP.

15. See, for example, letter from C. Mani, director, SEARO, to the Ministry of Health and Family Planning, GOI, May 2, 1967, File 416, Box 193, WHO/SEP.

16. Letter from Henderson D. A., chief, Smallpox Eradication, WHO Headquarters, to the surgeon general, United States Public Health Service, Bethesda, Md, September 6, 1967, File 416, Box 193, WHO/SEP.

17. Personal letter from Dr N. Maltseva, SEARO, to D. A. Henderson, chief, Smallpox Eradication, WHO Headquarters, June 27, 1967, File 416, Box 193, WHO/SEP.

18. Personal letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to Dr A. Oles, SEARO, September 14, 1970, File 416, Box 193, WHO/SEP.

19. For a reference to this, see personal letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to Dr Joel Brown, Los Angeles, May 12, 1970, File 416, Box 193, WHO/SEP.

20. See, for instance, personal letter from D. A. Henderson, Smallpox Eradication Unit, WHO Headquarters to Dr V. A. Muhopad, Lucknow, India, June 28, 1971, File 416, Box 193, WHO/SEP.

21. See letter from Dr N. Grasset, Smallpox Eradication Unit, SEARO, to D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, September 15, 1972, File 830, Box 194, WHO/SEP.

22. Letter from Dr N. Grasset, Smallpox Eradication Unit, SEARO, to Mrs I. Gandhi, PM, India, September 14, 1972, File 830, Box 194, WHO/SEP.

23. Singh Mahendra, “Report on a Visit to Study the Implementation of the National Smallpox Eradication Programme in Jammu & Kashmir (12 November to 27 November 1972),” c. 1973, p. 1, File 830, Box 194, WHO/SEP. Also see John M. Pifer, “Confidential: Smallpox in Bihar State of India During 1971,” c.1971, pp. 11–12, File 436, Box 193, WHO/SEP.

24. Personal letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to Dr N. Grasset, Smallpox Eradication Unit, SEARO, September 26, 1972, File 830, Box 194, WHO/SEP.

25. See letter from N. K. Jungalwalla, GOI, to Dr D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, December 12, 1973, File 948, Box 17, WHO/SEP.

26. Personal letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to Dr N. Grasset, Smallpox Eradication Unit, SEARO, March 5, 1973, File 830, Box 194, WHO/SEP.

27. Personal and confidential letter from Dr N. Grasset, Smallpox Eradication Unit, SEARO, to D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, Geneva, June 7, 1973, File 830, Box 194, WHO/SEP.

28. For examples of such official trends, see File 830, Box 194, WHO/SEP.

29. See, for example, Indira Gandhis October 1974. statement and the publications released in support by state-level officials, File 832, Box 197, WHO/SEP.

30. Ibid.

31. “Review on the Situation of Reporting of Smallpox, Investigation and Containment of Outbreaks, Bhopal Division,” c 1974, pp. 1–4, File 832, Box 197, WHO/SEP.

32.

For a good description of the experiences of American workers in South Asia, see P. Greenough, “Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973–75,” Social Science and Medicine 41 (1995): 633–645. [PubMed]

33. Dutta Mahendra, “Snakes and Ladders: An Untold Story of the Fight Against Smallpox in India,” unpublished typescript, c. 1980, p. 9, private papers of Mahendra Dutta.

34. Dutta, “Snakes and Ladders,” 13.

35. Letter from Dr N. Grasset, Smallpox Eradication Unit, SEARO, to D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, c. September 1974, File 388, Box 194, WHO/SEP.

36. Dutta, “Snakes and Ladders,” 9–11.

37. Ibid.

38. See, for instance, memorandum from SEARO to D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, c. August 1975, File 831, Box 195, WHO/SEP.

39. See letter from H. Mahler, director general, WHO, to K. Singh, minister of health and family planning, GOI, August 20, 1975, File 831, Box 195, WHO/SEP. Also see personal letter from L. B. Brilliant, medical officer, SEARO, New Delhi, to WHO Headquarters, August 20, 1975, File 831, Box 195, WHO/SEP.

40. See letter from V. T. H. Gunaratne, regional director, SEARO, to H. Mahler, director general, WHO, July 1, 1975, File 831, Box 195, WHO/SEP. Singhs TV broadcast was immediately—and widely—reported in the Indian press. See, for example, “Smallpox Wiped Out, Says Karan Singh,” Indian Express, July 1, 1975; “Small-Pox Eradicated, Claims Minister,” Times of India, July 1, 1975; “No Smallpox in India,” Hindustan Times, July 1, 1975; “Smallpox Eradicated,” National Herald, July 1, 1975.

41. See, for instance, letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to Z. Jezek, medical officer, SEARO, November 3, 1975, File 831, Box 195, WHO/SEP.

42. Personal letter from N. Grasset, Smallpox Eradication Unit, SEARO to I. Gandhi, prime minister, India, February 16, 1976, File 831, Box 195, WHO/SEP.

43. Letter from L. B. Brilliant, medical officer, SEARO, to Mr A.K. Chakravarty, Government of West Bengal, December 3, 1975, File 832, Box 197, WHO/SEP.

44. Letter from D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters, to L. B. Brilliant, Michigan, USA, c. September 1976, File 831, Box 195, WHO/SEP.

45. Letter from N. Grasset, Smallpox Eradication Unit, SEARO, to D. A. Henderson, chief, Smallpox Eradication Unit, WHO Headquarters and V. T. H. Gunaratne, regional director, SEARO, June 30, 1975, File 831, Box 195, WHO/SEP.

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