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.
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.
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