‘The Smallpox Eradication Saga: An insider’s view’ by Isao Arita
Book review – by Vivek Neelakantan
It is said that science does not advance without doubt. This is particularly true of The Smallpox Eradication Saga. Isao Arita chronicles the smallpox eradication programme as it unfolded under disparate circumstances from 1962 to 1980 through an insider’s perspective in countries such as Brazil, Indonesia, India, Bangladesh, Ethiopia, Somalia, and West African nations such as Nigeria, where the World Health Organization (WHO) implemented the smallpox eradication programme. These country-level experiences serve as crucibles to examine the evolution of eradication strategies from mass vaccination to surveillance and containment.
Pivotal to the global campaign to eradicate smallpox in 1966 were West African nations that had received US bilateral aid. West Africa revealed that smallpox transmission was slow and required close contact; it could be interrupted if the chain between the smallpox-susceptibles and contacts was broken. The vaccination of only a proportion of the population in the villages where the smallpox cases were occurring – using jet injectors – not only helped conserve vaccine but also proved that mass vaccination was less effective than surveillance and containment.
Indonesia demonstrated remarkable flexibility of strategy when the WHO launched the intensified programme of smallpox eradication in South-east Asia in 1967. Initially oriented towards mass vaccination of the entire population, the programme in Indonesia shifted towards vaccination of susceptible children. However, detection of outbreaks in Indonesia was weak. Therefore the national smallpox programme officer introduced smallpox recognition cards for effective surveillance, which the WHO then introduced worldwide. The Indonesian programme thus forced WHO policy makers to rethink the efficacy of strategies such as mass vaccination and searching for unvaccinated people. Containment – focusing on discovering smallpox outbreaks, vaccinating the villagers of the affected areas and contacts of the patient – was in fact the strong arm of the Indonesian programme.
By 1973, eradicating smallpox from India and South Asia was critical: these countries made up 95 per cent of the 135 000 cases worldwide. Arita and Vladimir Zigmund, a Czechoslovakian WHO medical officer, had envisioned active searches for smallpox cases, but these did not materialise as patients with chickenpox were mistakenly admitted into smallpox wards, contracted the disease and spread the virus. Containment was thus a weak ingredient in the Indian programme.
The Horn of Africa proved to be the world’s last reservoir of naturally occurring smallpox after the disease was eradicated from India in 1975. Efforts were hampered by conflict between the governments of Somalia, Ethiopia and Kenya. Arita attributes the 1977 success of eradication there to the collaboration and dedication of the programme staff in these countries, although the dense narrative of chapter 14 reveals that Somalia and Ethiopia differed on the source of the original outbreak.
Soon after countries became free of smallpox, the WHO adopted a range of innovative approaches ranging from pock surveys in West Africa to analysing varicella cases in the laboratory in Pakistan. Yet no further cases were reported. On 8 May 1980, the World Health Assembly concluded that the world had been freed of smallpox.
The book concludes by noting that the eradication programme succeeded despite delays caused by Cold War upheavals and that officials had in some cases needed to circumvent the WHO’s hierarchy in order to execute certain aspects of the programme, such as investigating outbreaks. Arita also briefly discusses the security threat posed by smallpox in the context of bioterrorism.
A number of points escape his attention, such as poor surveillance and the non-disclosure of patients in Indonesia, India and West Africa. Was this non-disclosure an expression of subaltern popular resistance (considering that chickenpox cases were mistakenly diagnosed as smallpox) by WHO officials and national health authorities? Arita’s investigation of Liberia highlights the presence of smallpox in villages and the Minister of Health’s suppression of epidemiological data. However, the book ascribes success to the WHO leadership without questioning why there were occasional differences between health ministries in Liberia and elsewhere and the WHO headquarters in Geneva.
Arita’s insider’s perspective and narrative style unearth the shortcomings of the WHO in the Indian state of West Bengal, where a WHO officer had misdiagnosed chickenpox cases as smallpox, causing much embarrassment. An important aspect of The Smallpox Eradication Saga is Arita’s ability to draw valuable lessons from the history of public health programmes such as the Expanded Programme of Immunization, development of new vaccines and surveillance against infectious diseases. The book is a valuable supplement to the existing historiographies of smallpox by relating the past experience of smallpox eradication to current public health programmes.
Arita I. The Smallpox Eradication Saga: An insider’s view. Orient Longman; 2010.
Vivek Neelakantan is pursuing his PhD at the Unit for the History and Philosophy of Science, University of Sydney.