**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, causing 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. Persistently visible right through the 1960s, these difficulties delayed the Indian national smallpox eradication programme (NSEP) and ultimately caused it to face complete collapse by the end of the decade. Smallpox cases in India and the world, 1950-1977
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 the detailed negotiations carried out by WHO representatives like Donald 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 went out of their way to meet senior Indian politicians, promise heightened levels of financial and technical aid, and, not least, assure reforms within the WHO regional office; these efforts at winning over Indian political support for the smallpox eradication goal received backing from the highest levels of WHO administration, as it was accepted that the failure of such a high profile public health campaign would adversely affect the organisation’s international standing. 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 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 The global eradication of smallpox is arguably the greatest achievement of twentieth century medicine. 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. Indeed, as the international polio eradication programme continues to suffer from serious structural difficulties, and as worried discussions about how best to cope with the possible outbreak and spread of a human variant of bird flu gather momentum, it seems that the lessons provided by the smallpox eradication could be extremely pertinent for governments and civilians alike. For instance, the smallpox story warns us that public health policies cannot be imposed with any confidence from the top. If anything, the smallpox eradication programme reveals the central importance of mobilising local bureaucratic, political and civilian support for public health programmes reliant on large-scale immunisation and isolation; it also reveals the significance of adapting public health activity and messages to a plethora local cultural mores and concerns, even though this policy is expensive. 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 symptoms. 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 and caused administrative problems for international and national agencies working with 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. This website is the result of two Wellcome Trust-funded projects, one of which was started in October 2005 at the Wellcome Trust Centre for the History of Medicine at UCL. Dealing with the case study of smallpox control and eradication East Pakistan/Bangladesh, it builds on a previous project that dealt with historical developments in India and resulted in several publications. This website has several goals, namely:
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