The control and eradication of smallpox in South Asia


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Smallpox was a devastating scourge. It was a highly contagious viral disease that killed up to half of those infected and seriously maimed survivors, through severe scarring of the skin with deep pock marks, blindness and infertility. However, those who did survive enjoyed protective immunity from further infection for the rest of their lives. The causative variola virus exists in more than one form, some producing more severe illness than others. Historical and epidemiological evidence suggests that South Asia was home to the more virulent strain of the disease – variola major, which sometimes mutated into the deadly haemorrhagic form of smallpox. On the other hand, the less virulent variola minor – also known as alastrim – was commonest in Europe and North Africa, where mortality levels were lower and haemorrhagic cases were much rarer.

The tools of modern science have yet to explain the relation between the different forms of variola, why some strains were more virulent than others or how some individual human physiologies were better able to respond to infection than others. However, there is broad agreement in scientific, medical and public health circles about one point - variola major could inflict a heavy loss of life amongst non-immunised populations, killing between 25 to 50 per cent of those infected, whereas the case-fatality rate for variola minor could be as low as 1 per cent. The other striking aspect of variola major was its well defined features: high fever, deep rashes, oozing pustules and a putrid smell were the norm, and a large percentage of the victims tended to die from bleeding, cardiovascular collapse and secondary infections. Haemorrhagic smallpox caused death rapidly from dramatic internal and external bleeding.


Poster advertising the benefits of vaccination and the dangers of smallpox, c.1970, Maharashtra, India, private collection of Dr. Sanjoy Bhattacharya ‌Historical evidence suggests that smallpox outbreaks were relatively regular occurrences in Asia, Europe and Africa. A range of sources also indicate that such events stoked widespread fear amongst members of the ruling elites, medical profession, social commentators and civil society, not least as it was recognised that smallpox did not respect political, geographical, racial and class boundaries. In fact, it was not uncommon for a mere handful of variola cases to foster great official and civilian nervousness, which meant that ‘epidemic emergencies’ were promptly announced almost as soon as a few specific cases were confirmed.

Smallpox epidemics could involve scores, hundreds or thousands of cases – the highly contagious nature of variola and its gruesome possibilities made number crunching relatively unimportant. Indeed, in colonial South Asia the discovery of a few cases was often considered to represent a prelude to the unravelling of a crisis that would inevitably result in further infections and innumerable deaths; while large-scale mortality was usually considered to be an affirmation of the dangers expected of variola, a less dramatic toll on human life was generally celebrated as an instance of good fortune.

The destructive reappearance of smallpox ensured that a variety of medical, political, religious and social players kept searching for effective means of controlling its spread. Continuing disagreements about the best means of countering the threat posed by variola meant that a range of approaches co-existed side by side; a feature visible across time and geographical location, as those stricken or threatened by smallpox picked and chose from preventives and remedies. Sometimes involving the use of the isolation of those stricken with the disease, smallpox control measures could also range from religious ceremonies (the worship of the goddess Sitala was widespread in South Asia) to the inoculation of humans with live variola virus (variolation) or more benign animal pox-based viruses (vaccination)

Smallpox recognition card, circa 1973, showing a child suffering from the disease, courtesy Dr. Damodar Bhonsule, Panjim, Goa, India‌Official policy documents from Asia and Africa, dating from the nineteenth and early twentieth centuries, sometimes refer to the goal of certain administrators to eradicate smallpox. In such cases, the term eradication was generally used to describe their relatively limited aim of banishing variola from the geographical confines of specific political units. The term eradication was used in a far more wholesome and ambitious sense in the decade following the Second World War, when the formation of the United Nations fostered the development of wide-ranging plans to tackle the global incidence of certain diseases. Although the first concerted international assault led by the Geneva-based World Health Organization was directed at malaria, Soviet delegates drew attention to the possibility of expunging variola globally in the late 1950s. The lobbying paid off, not least as there were fears within Europe and North America that smallpox could be reintroduced to those regions from countries where the disease was endemic, and the WHO Health Assembly made a concerted call for global smallpox eradication in 1958. This caused several national governments in Asia, Latin America and Africa to draw up blueprints for national smallpox eradication programmes, based on the plan to introduce 100 per cent vaccinal coverage within three to five years; the WHO’s stated goal was to provide technical assistance and inter-regional coordination, as and when it was required.

However, some national governments proved to be more committed to goal of smallpox eradication than others, which meant that the expansion of the global campaign was anything but uniform. Problems in this regard were compounded by the fact that the WHO’s early commitments to field activities remain unspectacular, which allowed countries like India, which had expected its programme to be bankrolled by UN funds, to develop its programme extremely slowly and unevenly. Therefore, while progress was reported and confirmed in Latin America by the late 1960s, smallpox remained firmly entrenched in Asia.

Annual number of smallpox cases by continent, 1959-1966**

Continent

1959

1960

1961

1962

1963

1964

1965

1966

1967*

Africa

16,307

16,823

26,060

24,329

16,863

12,506

16,784

14,127

9,554

Asia

71,309

39,843

53,957

63,616

98,784

43,537

39,145

50,494

50,958

Europe

26

47

24

136

129

--

1

71

3

North America

--

--

--

--

--

--

--

--

--

South 
 America

5,490

7,931

9,026

9,718

7,151

3,398

3,515

3,092

426

Oceania

--

1

--

--

--

--

--

--

--

Total

93,132

64,645

89,067

97,800

122,927

54,441

59,445

67,784

60,941


 **Consolidated data compiled by WHO from various sources 
 *Until 15th July 1967 
 Source: Smallpox Eradication – Report of a WHO Scientific Group: World Health Organization Technical Report Series, No. 393 (Geneva: WHO, 1968), 7, Official Publications Room, Cambridge University Library, UK.

Some parts of Asia were, of course, far more badly affected by smallpox than others. South Asia, composed of India, Bangladesh (East Pakistan before 1971), Pakistan, Sri Lanka, Nepal, Bhutan and Afghanistan was a major focus of endemic variola, which caused the WHO to scrutinise the situation in this region carefully. India, because of its size, its geographical, political and social diversity, and its regular smallpox outbreaks was identified as a particularly challenging field of operations. This characterisation was not misplaced, as the country began to throw up innumerable problems, ranging from political and administrative apathy to civilian hostility, from the very outset. Persistently visible right through the 1960s, these difficulties delayed the Indian national smallpox eradication programme (NSEP) and ultimately caused it to face impending collapse by the end of the decade.

Smallpox cases in India and the world, 1950-1977

Year

India

World

India/World Percentage

1950

157,487

332,224

47.4

1951

253,332

485,942

52.1

1952

74,836

155,609

48.1

1953

37,311

90,768

41.1

1954

46,619

97,731

47.7

1955

41,887

87,743

47.7

1956

45,109

92,164

48.9

1957

78,666

156,404

50.3

1958

168,216

278,922

60.3

1959

47,109

94,603

50.4

1960

31,091

65,737

47.3

1961

45,380

88,730

51.3

1962

55,595

98,700

56.3

1963

83,423

133,003

62.7

1964

41,160

75,910

54.2

1965

33,402

112,703

29.8

1966

32,616

92,620

35.2

1967

83,943

131,418

63.9

1968

30,925

80,213

37.8

1969

19,139

52,204

35.3

1970

12,341

33,663

36.7

1971

16,166

52,794

30.6

1972

20,407

65,153

31.3

1973

88,109

135,851

64.9

1974

188,003

218,364

86.1

1975

1,436

19,278

7.5

1976

Zero

953

--

1977

Zero

3,234

--

Source: R.N. Basu, Z. Jezek and N.A. Ward, The Eradication of Smallpox from India (WHO/SEARO: New Delhi, 1979), 36.

The Indian NSEP was rescued from complete breakdown by detailed negotiations carried out by WHO representatives such as Donald A. Henderson, then Chief of the Smallpox Eradication Unit in the WHO Headquarters in Geneva, who realised that its termination would spell the end for the global programme for smallpox eradication. For this reason, Henderson and his colleagues lobbied senior Indian politicians, promised heightened levels of financial and technical aid, and, not least, assured reforms within the WHO regional office.


The WHO’s negotiations with the Indian authorities, and its ability to mobilise significant funds for the NSEP’s needs from the Swedish International Development Agency, allowed the programme to be expanded gradually, with the active assistance of some Indian officials and politicians based in New Delhi. Indeed, India’s bilateral agreements with the Soviet Union for the supply of millions of doses of freeze-dried smallpox vaccine as aid proved crucial to the extension of NSEP and its ability to reach an intensified level of activity in 1973. Administrative and political hiccups were never completely banished, but were dealt with by WHO and Indian federal officials with a combination of diplomacy, aggressive negotiation, hard work and significant doses of good fortune.

Subsequent NSEP work – based on intensive searches for variola, the laboratory testing specimens collected from rash and fever cases, the isolation of smallpox cases and the vaccination of all their contacts – allowed India to achieve the so-called ‘Smallpox Zero’ status in 1975. This initially caused as much disbelief as relief amongst senior WHO and Indian government personnel, who had not expected to reach this stage so quickly. There was, in fact, much nervousness amongst WHO officials about the Indian authorities’ decision to advertise and celebrate the achievement, as they continued to worry about the prospect of finding a hidden pocket of variola in what was a vast country. These concerns ensured the retention of regular and comprehensive searches over the course of several months, which revealed, to the great relief of all concerned, that the country had remained variola free for two years. These findings were carefully examined by an independent committee, which certified India to be free of smallpox in March 1977.

It is widely acknowledged that success in India was crucial to the achievement of the global eradication of naturally occurring smallpox in 1980, which was ultimately achieved after the last few cases of the disease were tracked down in the Horn of Africa (the last case of smallpox, which was the result of a variola minor infection, was tracked down, isolated and cured by WHO-led teams in Somalia in 1977). At the same time, it is useful to recognise that the success of other South Asian national smallpox eradication programmes were important as well, not least as the territories of East Pakistan/Bangladesh had been badly affected by civil strife and environmental disasters through the course of the 1960s and 1970s. While the last case of smallpox in Pakistan was found in 1974, the eradication of variola in Bangladesh could only certified in the second half of 1977, due mainly to all the political and social upheavals faced by the new nation (the country reported the last cases of smallpox in Asia in October 1975).

Historical research: How and why


Photograph of Mr John Wickett of the World Health Organisation shaking hands with with the last person to have contracted – and survived – naturally occurring smallpox in Somalia (1977)‌The global eradication of smallpox is probably the greatest achievement of public health in the twentieth century. Historical research into the developments that made this feat possible is important both from an academic point of view, as well as an international public health perspective. There are many lessons to be learnt from a detailed historical examination of the unfolding of a multi-faceted campaign, based on the involvement of a range of international and national aid donors, in a diversity of political, social, economic and cultural contexts. For instance, the smallpox story warns us that public health policies cannot be imposed with any confidence on a top-down basis. If anything, the smallpox eradication programme reveals the central importance of mobilising local bureaucratic, political and civilian support for public health programmes. It also reveals the significance of adapting public health activity and messages to local cultural mores and concerns, even though this can be time consuming. Effective public health delivery, as WHO and Indian federal government officials realised during their tours of duty in the sub-continent during the 1960s and 1970s, involved much more than the clinical provision of a medical technology that promised to protect from a grievous disease. Instead, their experience in the field revealed that such work required intricate negotiations with those being targeted, as assurances had to be provided by vaccinal efficacy and safety, explanations provided about why someone had to be isolated and her/his contacts immunised, and, why young babies and children needed to endure painful post-vaccinal reactions. Indeed, many field officials found that forcible vaccination proved counter-productive in the long term, especially when such regimes were followed by serious post-vaccinal complications and/or death. Resistance to future investigative tours could be violent, or be marked by people’s refusal to co-operate or, even, based on them fleeing their places of abode en masse (or hiding others). Each of these tactics badly weakened the effectiveness of emergency measures, which prolonged campaigns, engendered administrative problems for international and national agencies, and placed extreme pressures on finite financial and personnel resources.


The studies on which this website is based have been made possible by generous financial support provided by the Wellcome Trust, UK.