Achieving the impossible
By Sanjoy Bhattacharya
Thirty years ago, people witnessed the fulfilment of a goal that many had considered impossible: the WHO’s 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 20th century. However, time has taken some shine off the accomplishment. I have encountered, all too often, in idle conversations and more formal speeches and writings, the argument 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; some commentators also argue, quite simplistically, that work was based on a strategy of searching for cases, containing infectious individuals and vaccinating their immediate contacts.
The situation was always more complicated throughout the course of a long-drawn-out global programme that was announced in the late 1950s, only really took off a decade later after a series of successful campaigns across West Africa, and took a further ten years to complete in a situation where the South Asian subcontinent 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, since WHO programme managers and national governments had to make significant efforts to persuade field officials to embrace new ideas and technologies. Notably, despite these efforts, some people remained indifferent to the calls for the introduction 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. Other challenges afflicted the campaign as well. Some sections of target populations opposed vaccination, which entailed delays and negotiations. There were, after all, limits to how much pressure the ‘smallpox warriors’ could impose on local politicians, junior governmental officials and civilian populations; diplomatic niceties could not be dispensed with altogether and international workers remained wary about stoking violent civilian resistance and resentment.
Other factors hampered the global effort as well. Support from within the WHO frameworks in Geneva and the Regional Offices remained inconstant, and often caused serious financial difficulties for work being carried out in the field; these challenges were only overcome in the 1970s with the assistance provided by a range of donors, such 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 this remained visible right to the end – some officials associated with national and local governments continued to oppose the eradication goal, often simply because they considered it misguided. 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; all these trends stoked doubts among bureaucratic and civilian constituencies, which translated into episodes where assistance was refused to teams of ‘smallpox warriors’.
We need to remember many positive aspects to the global smallpox eradication programme as well. A large number of participants remember – and 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, USSR and countries allied to each learned to collaborate with and 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 officials have preserved certificates thanking them for their involvement. There can be little doubt that there was goodwill among 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 meaningful projects such as the Expanded Programme on Immunization, whose components are widely credited for reducing levels of infant mortality around the world.
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 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 workers had dissimilar levels of commitment and ability. The contours of these variations changed over time and place, as there were shifts in the composition of teams and their interactions with national and local constituencies. Also, 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 crucial 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. Indeed, 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 this input was not summarily rejected. The multidirectional flow of ideas – and the resulting impact on field policies – is not always recognised or analysed by chroniclers of smallpox eradication. Yet these trends need to be studied sensitively and in great depth, as we celebrate the 30th anniversary of smallpox eradication, so that we can better present the many complexities characterising national and local vaccination campaigns.
A spirit of collaboration, in the widest sense, allowed the achievement of the impossible. So, as we celebrate a magnificent achievement in public health cooperation, we should consciously seek to refrain from reducing success to the contributions made by a few individuals associated with specific institutions. These people and organisations could not have stamped out the disease without extensive efforts from different health agencies and workers. 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.
Sanjoy Bhattacharya is a Reader attached to the Department of History at the University of York.