Global Smallpox Eradication

Podcasts and Interviews1980 witnessed the fulfilment of a goal that many had considered impossible. At the recommendation of an independent commission of experts, the World Health Organization’s (WHO) Health Assembly announced the global eradication of smallpox. It was a momentous occasion. In the view of many, with good reason, this was the greatest achievement of global public health in the twentieth century.

However, the passage of time seems to have taken some shine off the accomplishment in some quarters. Speeches and writings dealing with problems faced with current immunisation programmes argue, all too often, that smallpox eradication was easily achieved. According to this interpretation of events, the problems faced by the ‘smallpox warriors’ were relatively straightforward as the disease did not have animal hosts.

For further information, please contact Professor Sanjoy Bhattacharya, Director of the Centre for Global Health Histories at the University of York.

Some commentators also argue, quite simplistically, that the work was based merely a strategy of searching for cases, containing infective individuals and vaccinating their immediate contacts with efficacious vaccines. These arguments are becoming increasingly commonplace as a series of subjective histories are beginning to be used by global funding agencies and scientists in their employ to justify dramatic increases in funding for new immunisation programmes targeted at specific disease.

These trends make it all the more important to come up with a rounded history of smallpox eradication that does not reduce the success of a complex global programme to the ideas and actions of a handful of individuals, and the impact of a supposedly uniform and stable vaccine technology. 

A diversity of challenges

Rural vaccinator in United Provinces, British India, c.1930, private collection of Dr. Sanjoy Bhattacharya‌The situation was always more complicated throughout the course of a long-drawn out global smallpox eradication programme. Although it was announced in the late 1950s, the programme really only took off a decade later (after the completion of a series of successful campaigns across West Africa). Notably, its constituent activities took a further ten years to complete in a situation where the South Asian sub-continent and the Horn of Africa threw up a series of unexpected challenges. The mere presence of technological developments — such as the introduction of heat stable freeze dried vaccines, and the so-called bifurcated needle that contributed to vaccinal economy and safety— did not guarantee smallpox eradication. Human agency was an important determinant. Indeed, significant efforts had to be made by programme managers within the WHO and national governments to convince field officials to embrace new ideas and technologies. Notably, despite these efforts at persuasion, some people remained indifferent to the calls for the introductions of new operational methods and vaccinal products, choosing to stick to older procedures that they were more comfortable with and often regarded as being more reliable.

Poster advertising the benefits of vaccination and the dangers of smallpox, c.1970, Maharashtra, India, private collection of Dr. Sanjoy Bhattacharya ‌Other challenges continued to afflict the campaign as well. Some sections of the target population opposed vaccination, which led to delays in projects in some areas and introduced time-consuming negotiations in others. There were, after all, limits to how much pressure the ‘smallpox warriors’ could impose on local politicians, junior governmental officials and civilians; diplomatic niceties could not be dispensed with altogether and international workers remained wary about stoking violent civilian resistance. Force, when it was used, could create lasting resentment, which was recognised as being strategically unhelpful in the longer term.

Other factors also created difficulties for the global effort at smallpox eradication. Support from within the WHO frameworks in Geneva and the Regional Offices remained inconstant, and often caused serious financial difficulties for those working in the field. These challenges were only overcome in the 1970s with the assistance provided by a range of donors. Help was provided by sources as diverse as the Swedish and Danish International Development Agencies, the Indian and Bangladeshi governments, and, not least, the Tata industrial consortium in India. To make matters worse — and these trends remained visible right till the end of the campaign — some officials associated to national and local governments continued to oppose the eradication goal, often simply because they considered it misguided and damaging to the vitality of general healthcare facilities. In addition, competing health and financial priorities, alternative epidemiological understandings of smallpox causation and control, and a variety of professional and personal jealousies proved damaging. This stoked doubts amongst bureaucratic and civilian constituencies, which translated into episodes where assistance was refused to teams of ‘smallpox warriors’.

 Celebrating diversity and variation in practice

There were many positive aspects to the global smallpox eradication programme as well. A large number of participants cherish the internationalism that characterised it. For many, the campaign allowed a context in which cold war rivalries gradually dissipated, as several officials from the USA, the erstwhile USSR and countries allied to each of these countries learnt to trust each other. It is also worth remembering that many national workers regarded their participation in the project as a career highlight, allowing an intense and productive association with WHO frameworks. This attitude is well represented by the care and pride with which many officials have preserved certificates thanking them for their involvement in the eradication programme. There can be little doubt that there was goodwill amongst many ‘smallpox warriors’, despite differences in nationality, education, race, gender and age. For many young officials, participation in such a global programme led to new career paths, with international and government agencies, non-government organisations, universities and charities. A shared goal of saving lives drew many people together in the 1970s and ultimately gave rise to projects such as the Expanded Programme on Immunisation, whose components are credited for reducing levels of infantile mortality around the world by many observers.

However, all these positives should not be allowed to cloak important intricacies in operational strategy, especially as these are sometimes downplayed or ignored in celebratory treatises. The global smallpox eradication programme, which was composed of several national chapters linked by a series of international accords, was always marked by variations in official and civilian attitudes. Participants had differing visions about the efficacy of plans, and teams were composed of workers with dissimilar levels of ability and commitment. The contours of these attitudinal variations changed over time and place, as there were shifts in the composition of teams and their interactions with various constituencies in national territories and their locales. 

Image of the Vaiola virus, courtesy of J Cavallini/Wellcome Photo Library.

Significantly, the transfer of ideas about the best means of eradicating smallpox did not flow in one direction. Indeed, the most effective campaigns were generally those that were based on a proactive exchange of ideas between field personnel of different ranks and backgrounds. For this reason, regular meetings between international workers and national counterparts were regarded as being a crucial component of the programme in the 1970s. Many international workers were also able to play another important role —conduits for locally garnered information, which would otherwise have been ignored by those at the apex of national governing structures. Notably, WHO representatives were often able to put forward ideas presented by junior medical and paramedical staff who were in touch with the social, political and economic realities of specific regions; this frequently ensured that such input was not summarily rejected. The multi-directional flow of ideas — and the resulting impact on field policies — is not always recognised or analysed by chroniclers of smallpox eradication. These trends are worthy of sensitive and in-depth study so that we are better able to present the many complexities characterising international, national and local vaccination campaigns.

A spirit of collaboration, in the widest sense, allowed the achievement of the impossible. So, as a magnificent achievement in public health co-operation is celebrated, care should be taken to avoid reducing all successes to the contributions made by a few individuals associated to specific institutions. These people and organisations could not, on their own, have stamped out smallpox all over the world. Different health agencies worked with each other, with one stepping up to fill the breach whenever another’s strength was denuded by constant toil and required time to recover its vitality. Seen from this perspective, a complex association of institutions and people led to the stamping out of variola in its natural form; it is of paramount importance that we do not forget the contributions of the many people who contributed to the triumph. As Donald A. Henderson and others deeply involved in running this most remarkable and complicated public health programme remind us in a series of lectures and interviews, smallpox eradication would have been impossible without the dedication of a huge number of individuals. It is imperative that we do not forget that a vast majority of these people were drawn from the countries where the final battles against the variola virus were concluded. Many more voices need to be remembered and recorded, before they are lost to posterity. But, that is a job for future historians, for whom there remains a lot to study and better understand, not least as efforts continue to be made to learn from past experiences.