Talking about Ebola

The WHO Collaborating Centre on Global Health Histories supported by the Wellcome Trust has produced a series of seminars and webinars looking at the different ‘narratives’ of Ebola, and how this disease is a prime example of neglect in the global health context.

 

The full seminars can be seen and/or listened to here:

Haemorrhagic fevers: The deepest fears (GHH seminar 41, 12 May 2010)

Speakers: Professor Melissa Leach, Director of the Institute of Development Studies based at the University of Sussex; Asiya Odugleh, Alert and Response Department, WHO 

 

Ebola: exploring the cultural contexts of an epidemic (GHH seminar 91, 8 October 2015)

Speakers; Zsuzsanna Jakab, Regional Director for Europe. WHO; Jeremy Farrar, Director of the Wellcome Trust; Guénaël Rodier, Director of the Division of Communicable Diseases, Health Security and Environment at the Regional Office for Europe, WHO; and Dr João Nunes, lecturer in International Relations, University of York.

 

This briefing draws on the speeches and material presented at those seminars, as well as additional material from and discussions with Dr João Nunes.  

 

Ebola is not new. It was first officially identified and named in 1976 and successive outbreaks since then have killed thousands of people in different African countries. The virus has mutated between different outbreaks, which is one reason why the disease has consistently defied attempts to contain it fully – but this is certainly not the only reason. “The frenzy about Ebola was not accompanied by a systematic engagement with its broader context or the different degrees of vulnerability to it,” says Dr João Nunes, Senior Lecturer in International Relations, University of York.

 

Instead, Ebola is at the centre of myths and misconceptions – most of which portray the disease as somehow a terrifying inevitability, rather than the result of assumptions and decisions about who matters and who does not in terms of global health. “As a multidimensional, complex reality Ebola has been neglected,” Nunes says.

 

The myth of the dark continent

Ebola is undeniably frightening. It is transmitted through bodily fluids, and the symptoms include haemorrhage, kidney failure, lesions, and high temperature; it is highly lethal, with mortality rates of between one in four and nine out of 10; and it progresses very quickly, from first symptoms to death within a couple of weeks. There is currently no vaccine or antiviral treatment. On the other hand, it actually kills far fewer people than Lassa fever, which has a minimal mortality rate by comparison but is much more widespread. Professor Melissa Leach, Director of the Institute of Development Studies based at the University of Sussex, points out that Ebola is an “exceptional” or “master status” disease, which inspires a dramatic level of fear – on several levels. 

 

    Part of the reason for that status is the idea that Ebola is a disease that originated in dark African forest, perpetuated and spread by people and customs that are different, foreign, other. In fact, according to this narrative, the people who live in the areas where Ebola breaks out actively spread the disease further, through what they eat and what they do – so not only are they victims but they are perpetrators. 

 

    “Ebola is linked to ‘exotic African practices’,” says Nunes. “It’s heavily racialised; it cannot be separated from the persistent anxiety over certain types of groups.” Alongside that, he adds, there is “the underlying racist narrative which depicts the entire African continent as a homogeneous entity, a place of despair and helplessness. A place where things like Ebola ‘just happen’, because it is not possible to implement effective governance.” 

 

    The myth underpins and justifies an idea that Ebola outbreaks are, fundamentally, unavoidable tragedies. Yet the reality is that the outbreaks happen in regions that have been rendered vulnerable because of political, social and economic decisions. 

 

Customs and practices

Social customs do play a part in increasing the spread of Ebola. Some of these are associated with traditional healing, involving blood and unsterile knives. Others, though, are more about a refusal to maintain distance from the sick person (which has very obvious parallels with the arguments in other parts of the world over masks and/or social distancing during the COVID-19 outbreak). 

 

    And in fact, some practices fit in very well with other medical beliefs about how to contain the spread of an outbreak. Leach points to the Acholi people in Northern Uganda, who isolate patients, encourage people to stay in their own homes, and keep people who have recovered within their homes for a further month. All these measures are completely in line with what Leach describes as “the biomedical cultural model employed by international teams”. 

 

    Guénaël Rodier, former Director of the Division of Communicable Diseases, Health Security and Environment at the Regional Office for Europe, World Health Organization (WHO), also points out that traditional healers and funeral practices are not the only reasons for the spread of Ebola. “More importantly it is amplified by hospitals and the health system. With all large outbreaks, the health system plays a major role in the amplification of the disease.”

 

Ebola stories

Leach identifies four different Ebola ‘stories’ – the versions of the disease and its context that all contribute to how this disease is considered and treated as a global health emergency. They vary according to who is telling the story; how the ‘problem’ is defined; who or what is considered responsible for the problem; whose knowledge is valued; and what strategies are considered useful in tackling the problem. “In looking at stories you can begin to clarify some of the choices and cast sharper light on how to go about some of the practical issues.”

 

    The first is the global threat – the plague which emerges from Africa (that dark continent) and needs to be stopped from spreading across the world. Much of the worry is about how a virus that comes from ‘over there’ can come to affect ‘us’, and indeed people often talk as if the virus has some kind of agency of its own. This is the model that has underpinned much of the international perspectives on outbreaks. “Ebola is an archetype for this ‘outbreak narrative’,” says Leach, pointing out how much of the response to Ebola has been motivated by fear. This is also the story that we have seen played out in fiction and in film (most recently in the film Contagion, which was watched by countless people in lockdown in the spring of 2020, as cities emptied and the death tolls climbed). In the fictional versions there is usually a medical solution where the white-coated (and usually white) scientists finally conquer the threat.

 

     The second is the one of deadly local disease events, and mounting a rapid response against them, which has gained more traction in recent years. The emphasis here is on containing a short-term and local – though deadly – outbreak. The local people are again mostly ignorant and/or misguided, perpetrating dangerous practices; and authority (and the solutions) lies with what Leach terms the “standardised technical response package” of isolation, contact tracing and barrier nursing. 

            

    The third is based on culture and context, and reverses some of the assumptions in the other two models to put the people and communities that are affected by the disease at the centre. Ebola and similar diseases are, after all, not new, and people have built up knowledge and medical/cultural practices that may well overlap with the practices that of other medical disciplines (like the Acholi strategies of social isolation). Even when the local practices are in conflict with ‘mainstream’ medical approaches, they cannot be overridden without thinking. 

 

    Finally, there is a narrative of mysteries and mobility, which has been evolving since around the mid-1990s. This is in some ways a group of different stories, bringing together the environmental-social-animal-disease-ecological systems that are all associated with Ebola; from migration to political systems to climate change. Leach describes it as “a much less coherent narrative” but also “very exciting”, as it draws attention to a whole variety of overlapping issues that drive the spread of the disease. 

             

    These last two narratives move away from the top-down, standardised responses to Ebola (and other diseases) which many people in the area resist in any case, because these is imposed on them whether or not they agree. The last, importantly, also moves away from seeing Ebola as a solely medical issue. All too often, says, Nunes, Ebola “is framed as an African problem that requires surveillance and containment. The focus is on preventing infection and containing disease, which runs the risk of overlooking the broader context that makes the crisis possible in the first place. Crucially, there is almost no attention on the wider social and political context.”

 

    Nunes brings in another perspective; that Ebola is part of the “complex issue of neglect in global health”. Neglect, as he defines it, maybe the failure to care about an issue at all, or the failure to take address it adequately – either because it isn’t considered sufficiently important, or because the action that is taken is not competent and/or adequate. “It’s about a moral landscape and a political arena in which effective political solutions are not imagined or mobilised.” 

 

    Neglect, he explains, doesn’t somehow emerge on its own; it is the result of the context and the culture, the assumptions about the disease and the people that are affected by the disease. ”At the crux of the production of neglect, it is always possible to locate human agency and choices. Issues are rendered invisible because certain actors follow certain purposes. Neglect should not be considered mere invisibility, but rather a process of making something invisible and denying an adequate response.”

 

    And emotion plays a very strong part in this too. Ebola is associated with people that are thought of as “alien, outside the sphere of moral obligation, disgusting, beyond the possibility of any moral improvement”. They have become effectively invisible; their needs and suffering don’t count as much as the needs of people who somehow ‘count more’. It’s not that Ebola gets no attention or sympathy. But it is depicted as a strange and frightening disease – one which hits the headlines briefly and then drops out of public focus. “The same forces that made it trending contributed to its construction as exotic.” It is treated as an emergency – time and time again – when in fact it is the result of a set of endemic, rooted problems.

 

Local resistance

“Ebola is not a rare event,” says Jeremy Farrar, Director of the Wellcome Trust. “It is a series of epidemics – and with each, we have failed to respond. We need to have systems that can prepare for it and act.” “It is possible to control outbreaks without sophisticated tools,” Rodier adds. “It is people-centred. Each contact is a person and needs to be on board, and to break the chain of transmissions need to know who has been in contact and follow them up. It is not highly transmissible.” Yet many people who are all too well aware of the devastation that Ebola can inflict refuse to comply with the advice and the practices imposed by medical staff.

 

    That can be partly because other diseases – HIV, malaria, water-borne disease and others – are often endemic in the areas where Ebola breaks out; and in practice, these may be more of a priority for local people. But it’s also the case that some of the things people are asked to do, in order to prevent or treat Ebola, can be distressing and/or can clash with their usual beliefs and practices. Leach cites an outbreak in Gabon in 2001, where villagers actually mounted an armed resistance to medical teams because in previous outbreaks sick and dead people had been taken to isolation units and there was a fear that their body parts were being stolen. Rodier gives the example of young male Red Cross workers removing bodies, in a culture where women are usually in charge of healthcare and the care of the dead, and putting them in black bin bags whereas the colour associated with death is white. Sometimes a team of health workers has arrived ahead of an outbreak which was spreading towards a locality, even before the disease itself, so it looked as if they themselves were responsible for the sickness and deaths. People distrust the motives of what they perceive as ‘the Ebola business’; their own ways of doing things are being ignored; and at the same time, the shame and stigma about Ebola and people who survive Ebola is also still a very powerful social issue. “When you look of the typology of the resistance, it was perceived as fighting ‘a war against us’, in the belief that the international community was spreading the disease,” Rodier explains. “Sometimes you can understand why they believed it.” 

 

Changing and uniting

“If I have suggestions, it would be about drawing some of these narratives together,” says Leach. They all have elements that can be useful: and in practice they interact and evolve together in any case. Leach suggests, in particular, integrating the ‘outbreak narratives’ with those of longer-term, endemic disease; the global perspective with the local; and sustaining the focus on culture and context, while extending it to include the “environmental dynamics” of disease. 

    The narratives are changing, too. The world in which Ebola breaks out today is a very different from the world of the 1976 outbreak. “The virus has not changed dramatically,” says Farrar. “What changed is the cultural context.” People are moving at an unprecedented rate, and moving from villages into cities and from cities across the world. “Societies are different, the way in which societies work together is different, the way individuals behave is different. So we have to think forward not backwards and look at the world as it is today and will be in the future.”

 

    As part of this, health systems and services need to do things differently as well, he argues. “Health systems around the world were established in an era of infectious diseases when relatively young people got ill, came into the hospital, and either recovered or died. The new world is very different. The dreadful tragedy of Ebola gives us an opportunity to redefine how we do things. The 21st century will bring challenges we’ve never faced before but we are also at the dawn of a golden scientific age. We should not be separating, we should be pulling together, including with the clinical solutions.”

 

    “We need alternative framings of Ebola that consider power inequalities, the relations between groups and the production of harm, vulnerability and structural violence in the international sphere. It is frustrating going over the same debate each time instead of thinking more systematically about the status quo that seems to accept that crises will occur and human ingenuity will get us through,” Nunes concludes. “We get unnecessary suffering, unnecessary deaths and millions in wasted resources. We are not united by contagion. We are divided by the global structures and relations that create the privilege of some and the vulnerability of others. Swift decisions are important but short-term policies shouldn’t be the sole focus of global health governance. We need first and foremost a strong political commitment.” 

 

Radhika Holmström is a writer and communications specialist working with the Global Health Histories project at the University of York.

Laying the foundations for eradicating smallpox

The WHO Collaborating Centre on Global Health Histories supported by the Wellcome Trust has produced a series of seminars and webinars which discuss the WHO’s successful programme to eradicate smallpox, focusing on a diverse spread of national drives early in the programme which were integral to its eventual success.

The three seminars can be viewed and/or listened to here:

The fruits of a new internationalism?: South Asian governments, the WHO and global smallpox (GHH seminar 26, 2 October 2008)

Speaker: Dr Sanjoy Bhattacharya, now Professor in the History of Medicine and Director of the Centre for Global Health Histories at the University of York and of the WHO Collaborating Centre for Global Health Histories. 

 The Creation & Expansion of the Worldwide Smallpox Eradication Programme (GHH seminar 121,March 2019)

Speakers: Lu Chen (University of York), Dr Susan Heydon (University of Otago), Dr Carlos Campani (University of York) and Dr Namrata Ganneri (University of York and SNDT College of Arts & SCB College of Commerce and Science for Women, Mumbai).

Smallpox eradication 40 years on (Cultural Contexts of Health (CCH)* and GHH 138 webinar, 5 November 2019)

Speakers: Dr Namrata Ganneri (University of York, and SNDT College of Arts & SCB College of Commerce and Science for Women, Mumbai), Mr John F Wickett, World Health Organization (retired). 

*The CCH webinars are a subset of the WHO GHH seminars, delivered for the CCH project based in WHO Europe

This briefing draws on the speeches and material presented at those seminars.

 

On 8 May 1980, the World Health Organization (WHO) made a declaration which would have been considered impossible only a few years earlier: the disease smallpox was declared eradicated from the world. To date, no other human disease has been eradicated in this way.

 

It followed a concerted programme coordinated by the WHO to eradicate smallpox, first discussed at the World Health Assembly (WHA) in 1957, and proposed and voted in the WHA of 1958. Most attention has focused on the so-called ‘intensified phase’ of the eradication programme from the late 1960s onwards. Yet this was only made possible by the work that preceded it: a range of very different drives in different countries.

 

Some of those early drives were partial, and/or dependent upon the political and socioeconomic context. All of them were produced at a time when technology, understanding and access were very different from today. They cannot be summed up as a simple set of strategies that ‘worked or didn’t work’. But they did provide the initial data about a range of socio-political contexts, and this in turn justified the continuation and extension of the entire WHO programme. They were an essential precursor to the ‘intensified phase’, and specific themes certainly do emerge from their work. 

 

The WHO smallpox eradication programme

Over the past 40 years the effects of smallpox have often been downplayed. In reality, the disease, particularly the more lethal form of variola major, had posed a major threat for thousands of years. Those who survived (and many did not: some estimates suggest that variola major had a mortality rate of up to one in two) might be blinded, made sterile or otherwise damaged – and, obviously, often significantly disfigured by the characteristic ‘pockmark’ scars. 

 

The difficulties of eradicating smallpox have also been downplayed. Although smallpox does not have animal hosts, it is highly infectious. Nor was it possible, even in the 1950s, to confine eradication to specific locations. One message that comes through very clearly from the earliest years of the eradication programme is that ‘disease is global’, and that it can be repeatedly reintroduced to areas which have been declared free of infection. The original proposal in 1957 to the WHA which led to the WHO’s smallpox eradication programme (SEP) came from the Soviet Union, which had attempted to eradicate the disease but found that had been reintroduced several times. 

 

The SEP involved a lot of complex negotiations (including over funding and supplies of vaccine and equipment) and encountered a series of unexpected challenges. It gained traction and support from 1967 when the programme was officially ‘intensified’. Yet, points out Professor Sanjoy Bhattacharya, director of the Centre for Global Health Histories at the University of York and of the WHO Collaborating Centre for Global Health Histories, “there is detailed evidence-based research which shows that international engagements between 1958 and 1967 were rich and important”. In four areas in particular, vaccination and surveillance programmes had made significant progress by the time of intensification – and the evidence from those made it easier for international groups of officials to advocate the wider programme.

 

More centralised approaches: China and Brazil 

In China the disease was eradicated without WHO involvement, and before the intensified programme started. China is, however, a very specific case, having withdrawn from WHO membership completely under the Communist government. “Smallpox eradication was carried out within local health structures, and the political and social and geographical and cultural and epidemiological realities,” says Lu Chen of the University of York. 

 

In the 1950s, smallpox was highly endemic in China – not as much as in India but more than in other bordering countries – and one of the most fatal diseases in the country. The Chinese eradication programme started in 1950, with a mass vaccination programme for the whole of mainland China. The three main rounds of vaccination (1950 to 1953,1955 to 1958 and 1960) eliminated and/or reduced the disease considerably in a number of areas, but it was repeatedly reintroduced. “It was a continual process of elimination in different areas,” Chen explains. The last case was found in 1965, before the WHO increased communication with China.

 

The Chinese programme was carried out at a time when China was experiencing very low economic growth, and food was scarce. Yet it still managed finally to eliminate smallpox in the country. This was very much part of a wider government commitment to improve public health in general. “Disease and poor sanitation were considered an enemy of progress,” says Chen. “It was highly political and ideological.” There was a widespread health education campaign, using a number of different media and popular art forms. All children were vaccinated periodically from the ages of six months to 18; and any new cases were to be reported to the authorities within a matter of hours. 

 

In the late 1970s China finally engaged with the WHO and submitted a country report; it received certification as smallpox-free in 1979. It was the achievement, as Chen says, of “national and regional health officials, research scientists, local health workers and vaccinators. We need to acknowledge the names unknown; stories untold; and voices unheard.”

 

In Brazil, a centrally-driven programme was actually made possible as the result of a military coup in 1964. The earlier, more dispersed, programmes were centralised as a result – and, importantly, the new government wanted national and international recognition and legitimacy, which an eradication programme could provide. The last case in Brazil was recorded in 1971.

 

Smallpox had posed less of a threat in Brazil than in China, but there were major outbreaks every three to six years, especially in the ports – with a knock-on effect on commerce. “Every disease that disrupted international commerce was a priority for public health,” explains Dr Carlos Eduardo Campani, who is now at the Royal London Hospital. Compared to other diseases, however, smallpox was increasingly considered less important, especially after 1930 when variola minor became the more prevalent form. “It was accepted as minor and curable, and no longer a priority,” says Campani. Smallpox became the responsibility of small local agencies, and vaccination was mainly carried out only in urban areas. Pockets of the disease remained, and it was reintroduced from neighbouring countries. 

 

The Pan American Health Organization (PAHO) launched a continental eradication programme in 1950 but vaccination remained decentralised to local programmes. Even after the WHO programme was launched in 1958, and decisions about smallpox policy were made centrally, Brazil lacked resources and above all the vaccine to combat the disease effectively. When a national campaign against smallpox was launched in 1962, with vaccine provided by government, it was still hugely inconsistent. “The 26 different states organised their own programmes,” says Campani. “There was a lot of variation in how they approached the problem, and two big problems: it was heavily underfunded – there was no funding for vaccination at all 1963 – and there was a lot of political instability at that period.” Yet nearly 24m people were in fact vaccinated between 1962 and 1966, when the health ministry took over the programme, with the goal of vaccinating 90 per cent of the population and Brazil started working with WHO technical support and funding.

 

 “When you’re asked about how long you’ve been married, I believe you should date it back to when you started to date. The whole history is important for your marriage,” Campani points out. “And similarly, you can’t lose the story of smallpox eradication before 1967 in Brazil. National particularities must be taken account of. If we lose that, we lose the evidence of how the support was built on the ground for political decisions.”

 

More decentralised approaches: India and Nepal

India is the part of the world where smallpox has been most endemic since earliest history. It is the home of variola major, with major epidemics every five to seven years and seasonal peaks between December and May. There were also complex historical, social and religious associations with the disease (see below). Yet the early stages of India’s own eradication programme, launched in 1962, only granted limited WHO involvement. And when the WHO SEP entered its intensified phase India – unlike nearly all the other 34 countries where smallpox was endemic – did not immediately set up a WHO-assisted campaign.

 

However, work from India made a significant contribution to the SEP. Dr Namrata Ganneri, Commonwealth Rutherford Fellow at CGHH and the History Department, University of York, and SNDT College of Arts and CB College of Commerce and Science for Women, Mumbai, has charted the contribution of Indian health officials to the WHO SEP: in particular the work of Dr KM Lal, the director of the National Smallpox Eradication Programme (NSEP). Dr Lal made a presentation of his findings to the first WHO expert committee in January 1964 which set a target of 100 per cent of the population in its first ‘attack’ phase, in all probability drawing from the Indian experience. The WHO records also singled out the use of family registers and independent appraisals of the programme in different parts of India as a template for national control programmes in other countries, along with ‘concurrent evaluation’ (evaluating the programme as it was being carried out). 

 

The first pilots for the Indian NSEP were set up in 1959 after a massive outbreak of smallpox (and also cholera) the previous year. Specially recruited teams moved systematically from house to house and from village to village throughout a district in an effort to vaccinate or revaccinate not less than 80 per cent of the population, with the aim of creating herd immunity so that transmission would terminate spontaneously. Alongside this, ‘enumerators’ compiled comprehensive registers for each area, to check that sufficient numbers had been successfully vaccinated. After the first round of vaccinations, local health units were responsible for vaccinating people omitted from the first programme. 

 

Finally, there was an injunction to revaccinate every five years, and to vaccinate the contacts of anyone who did contract smallpox – because, despite the programme, there were still repeated outbreaks of the disease, including a major one in the winter of 1963 after which the target was changed to 100 per cent vaccination coverage. The programme was repeatedly assessed and evaluated, and successive reports were produced; and while WHO involvement remained limited it was at least increased. 

 

India did eventually respond to the intensified programme. More vaccine became available, as the result of bilateral agreements between different states; and, importantly, the Indian programme also became more centralised. “With a powerful centralising Prime Minister, assurance of more funding and more vaccine, states started to come on board and the government started to increase its financial input,” says Bhattacharya. “The government cleared many more international personnel to work in India and WHO officials were able to work more efficiently with district officials and at village level.” However, Ganneri points out, the work of the previous years underpinned both the Indian and the global SEP. “The global programme itself was rapidly changing and drawing on experiences from the field, and the Indian experience became central to the WHO eradication strategy. Perhaps it is time to study national stories upwards rather than from the international level down.”

 

Nepal was one of the last areas to eradicate smallpox; it was classified as no longer endemic in 1973 and the last case was in 1975. The WHO’s attitude to Nepal moved “from despair to praise,” says Dr Susan Heydon of the University of Otago as the country finally succeeded in a mass vaccination, surveillance and control programme.

 

Nepal did engage with the WHO, starting with the smallpox control pilot project known as WHO Project Nepal 9. Cooperation and involvement with Nepal through the WHO’s South-East Asia Regional Office (SEARO) “offered a strategy for Nepal, with its limited resources, towards achieving its own goals for better health services”, Heydon explains. This included support for a smallpox control pilot project to start in early 1962 in the Kathmandu valley, aiming to build a ‘nucleus’ of vaccination activities and expand ‘as and when possible’ to other areas. Although it had the huge advantages of freeze-dried vaccine and fridges for storage (see below) the project encountered a number of setbacks – outsiders constantly underestimated the enormous logistical difficulties – and the annual field visits from SEARO consistently found that despite the large numbers of vaccinations and revaccinations, numbers simply were not enough to achieve control. 

 

In 1965 the government of Nepal decided independently to extend the programme, and the following year the government and WHO drew up a revised plan of operation for ‘smallpox eradication and control of other communicable disease’, which superseded the previous project.

 

Alongside this, Heydon highlights three rather different initiatives which also ran before the intensified SEP. One was the 1965 locally-initiated and organised Medical Association drive to vaccinate all children in Morang and Sunsari districts, Kosi Zone. Working with the panchayat (district authority) and local structures, this achieved higher vaccination rates and coverage than the WHO pilot project. “The pilot was the largest communicable disease programme then in Nepal, but it achieved but low coverage,” Heydon points out. “This local initiative in 1965 showed how it could be better.”

 

By contrast, the other two initiatives involved “non-expert foreigners” – responding, importantly, to local demands and requests. The first was in the Mount Everest area, where Edmund Hillary’s Mount Everest expedition team met its first case of smallpox near the village of Lukla on 12 March1963. The epidemic was by then starting to spread between the valley villages. Hillary’s team set out to vaccinate as many people as possible, operating independently and mainly using vaccine obtained from the WHO representative in Kathmandu. They eventually vaccinated around 7,000 people. 

The second was in the Lamjung district where Peace Corps volunteers Don Messerschmidt and Bruce Morrison worked again through the panchayat to organise nearly 20,000 vaccinations in early 1964 – although they, like the Everest team members, were not officially health workers. There were effectively no health services in the area, and Messerschmidt and Morrison had considerable difficulty in obtaining sufficient supplies of vaccine (see below). 

 

“These early years highlighted many challenges but also offered ways forward and around,” Heydon points out. “The later success built on these foundations. And the goal was worldwide eradication: so small countries matter and need to be part of the history.” 

 

Beliefs about smallpox and vaccination

In a number of countries (such as Brazil at the beginning of the eradication programme there) health officials felt that a smallpox drive was the wrong priority for healthcare resources and priorities. As a result, vaccination teams were sometimes refused assistance (and this continued right through the intensified programme). 

 

In China, vaccination was already widely accepted, although there was some resistance in border areas and areas with a non-Chinese minority population. The vaccinators were selected from local cadres, local teachers and medical students (since there were not enough medical personnel). “These people were already familiar and trusted, so its was easier to get people vaccinated,” Chen explains. Alongside this, the government targeted the population – over half of which was still illiterate – through peer pressure from local cadres, broadcast media and traditional folk art performances. The message was highly political and ideological: vaccination was presented as a way to protect against the threats from the US, Russia and bacteria. 

 

India, by contrast, presented some very different challenges. The whole issue of smallpox vaccination already had a long and complicated history, and there were a number of beliefs that vaccination itself was dangerous and would inflict damage (for instance, that it caused people’s hands to fall off). There was also a complex range of beliefs specifically about smallpox, particularly in terms of the balance between heat and cool. “For Hindus, smallpox was seen as a visitation from the goddess Sitala (or Mariyamman in South India). Smallpox can arise also from her wrath but she also has the power to cool the disease and prevent it being fatal,” says Ganneri. Smallpox is also seen by the Ayurvedic medical tradition as the result of an imbalance between heat and cool. 

 

“It wasn’t a simple opposition of science versus irrationality and/or religion,” explains Bhattacharya. “People could believe in several remedies simultaneously; and indeed many people first had their children vaccinated, and then took them to be blessed in local temples.” “Religion is important but not as important as it may be made out to be,” Ganneri adds. “Traditional ideas about cause and treatment are very important as the backdrop to the eradication programme.” In fact, she points out, the main resistance came not from the rural but from government officials and from the more educated population. For instance, vaccination meant one was unable to work for several days; the vaccinators usually came from the so-called lower castes, which meant they might be refused access to upper-caste households; and so on. “Complex stories need to be unravelled about what we see as resistance and what we see as acceptance. Resistance needs to be understood on its own terms.”

 

“Vaccinators had to convince repeatedly that vaccination was safe. I think the active voices of local health officials did get across, and this was an important part of negotiations,” says Bhattacharya “Efforts were made to find if others believed those problems would arise more widely and if so, the best way to negotiate with the elders and/or headmen.”

 

Logistics and delivery

One huge issue was the availability and also the type of vaccine. The liquid (glycerinated) form of the vaccine needed to be kept refrigerated at all times, whereas the freeze-dried form only needed to be kept away from direct sunlight. China was in the ideal position here: the country manufactured its own freeze-dried vaccine, and different manufacturing areas covered different areas of the country, so there was no need to import large quantities.

 

Other countries were in a very different position. In Brazil, the early rural projects before 1962 only received the liquid vaccine (freeze-dried was used in a few urban areas). India produced its own liquid vaccine but also received freeze-dried vaccine from the Netherlands and (after complex negotiations) from the Soviet Union. Scandinavian countries were also ready to pass on the technology for producing a vaccine. It was not till the intensified programme got underway that large amounts of Indian-manufactured freeze-dried vaccine became available.

 

Along with the vaccine itself, teams needed fridges to keep it in – and especially in these early years this could be a major sticking-point. In Nepal, however, although the WHO Regional Office for South-East Asia did make provision for refrigeration and also made the freeze-dried vaccine available, a lot of logistical problems remained. “One of the big issues was actually getting started,” says Heydon, pointing out that agencies consistently underestimated the difficulties of getting almost anything achieved. This was a country without roads, and where a phone call between Lamjung and Kathmandu was routed through 14 different operators – which was why over the Christmas of 1963 the Peace Corps volunteers Morrison and Messerschmidt simply walked to the capital, taking several days, in order to get hold of more vaccine. John Wickett, who worked with the WHO, recalls how the day-to-day issues of organising and servicing vehicles were absolutely crucial. “To maintain the key strategy of surveillance of outbreaks, you had to have the mobility of staff. If you didn’t have a vehicle or some means of transport you weren’t going to get the outbreaks contained.” That might mean trucks, boats, or even helicopters.

 

Finally, vaccinators were not always well-trained in their work; and quite a few refused to adopt newer products or vaccination techniques In Brazil, some teams initially used ‘jet injectors’ from a fixed location, whereas others used ‘multipuncture’ techniques, going from house to house, till the first method was shown to be both more efficient and much cheaper. 

 

The move towards a global programme

Eradicating smallpox was a huge achievement. It took many attempts, in different parts of the world, with different levels of success: from the government programmes in China to the two-person volunteer drives in Nepal. Some (notably China) did not engage with the WHO SEP at all. Others used a mix of foreign assistance and national or local work. None of them were possible if the people at risk of smallpox refused to be vaccinated. 

 

“The world needed to work together to ensure that smallpox was gone for good,” Bhattacharya concludes. “That is where history can help, to point out the particular conditions existing in different localities where challenges were met and overcome. And there is no doubt that this enables us to prepare for future outbreaks of infectious disease.”

 

Radhika Holmström is a Wellcome Trust-funded writer and communications specialist working with the WHO Global Health Histories project at the University of York.