The Fruits of a new internationalism?

:

South Asian governments, the WHO and

global smallpox eradication

Sanjoy Bhattacharya, Ph.D.

The Wellcome Trust Centre for the History of Medicine, University College London, UK.

E. Mail: joygeeta@hotmail.com & sanjoy.bhattacharya@ucl.ac.uk

Please feel free to get in touch – would love to hear from you!

Smallpox – The disease….• Broadly speaking,

smallpox had two forms

• Variola major, which could kill 30-50 per cent of victims.

• Variola minor, which was much milder and killed about 1-3 per cent of victims.

Smallpox the disease….• South Asia was

mainly affected by variola major

• Smallpox outbreaks were, therefore, considered to be major events by government officials and affected communities

Smallpox control efforts in South Asia – a long history

• Inoculation – a wide range of styles existed across the sub-continent

• Isolation – again, different kinds practiced

• Vaccination – yet again, changed over time and location.

The WHO headquarters’ interest in smallpox eradication….

• The WHO’s health assembly interested in the question of global smallpox eradication in the late 1950s.

• Its 1958 resolution ratified the motion led by some members representing the Soviet Union at the Health Assembly, to move towards global smallpox eradication (‘Zdhanov resolution’).

Impact on South Asia….• Ratification of ‘Zdhanov resolution’ led to country level

negotiations.• South Asian national governments central in this regard.• South Asia was the largest reservoir of smallpox in the

world.• India and East Pakistan/Bangladesh contributed the

largest number of cases in the region (about 80 per cent of the cases worldwide in certain years; almost 60-70 per cent on a regular basis).

• Natural then that these countries would became an important focus of the global smallpox eradication programme.

The WHO & South Asian national governments

• Discussions between the WHO, and the governments of India and Pakistan in early 1960.

• Discussions also with - WHO’s regional offices (New Delhi & Alexandria).

• And – importantly - international search for money & other material aid.

• Scaling up of operations across South Asia: 1967- 1968.

WHO personnel & Indian government structures….

• The intensified programme – late 1960s and 1970s

• Indian government cleared personnel before they were allowed into the field

• Generally speaking, arrangements were made for WHO field officials in India to work closely with district-, sub-divisional and village-level administrators.

‘Special zones’• East Pakistan in 1970-71 (civil war/Bangladeshi war of

independence).• North Eastern India in 1973-76 (regional rebellions and

an Indian army backlash).• Bangladesh in 1975-77 (coup leading to slaughter of

ruling family, followed by setting up on a pro-Pakistan & pro-US government caused civil war like conditions).

• Led to the creation of a series of politically sensitive ‘special zones’ -- specific working conditions enforced on WHO and other NGO workers.

• Rules were broken – but, this involved significant element of risk!

Local administrative complexities

• National governments also remained in touch with funding/donor agencies on a bilateral basis

• Example - the Soviet Union an important source of donations of vaccines and vaccinating kits for India

• Why are all these details about administrative/political structures at global, international, national and local level important?

• Mainly as it affected all aspects of the organisation of national smallpox eradication campaigns – a generalisation valid for all countries in the region

India• India - Relatively stable

politically• Indian government insisted

on ‘clearing’/vetting foreign workers for service in India

• The Indian authorities also pushed for the formation of ‘mixed teams’

• Particularly the case in the troubled North Eastern states of India, bordering China, Bhutan & Bangladesh

• Parliamentary misgivings!

Pakistan and Bangladesh….• Pakistan - eastern wing in political

crisis from the late 1960s.• ‘Porous’ borders – seasonal

movement of workers.• Waves of refugees.• International workers associated

to the WHO often seen as politically neutral.

• Generally allowed to continue searches and immunisation work by all warring parties.

• Workers associated to particular foreign countries, like the US (CDC officials), were viewed with suspicion by the ‘rebels’ in East Pakistan in 1970-71.

• Indian officials were unwelcome in Bangladesh before 1972 and after 1977

Range of smallpox eradication work…. The Cold War….

• All these political developments affected vaccine import, local production and usage

• Smallpox vaccine imports - both purchases and donations - were deeply affected by international politics/ ‘Cold War’ rivalries.

• Smallpox vaccination production was also similarly affected.• Great variations across nations and their territories -- unity of

practice largely theoretical).• Bilateral aid agreements – a sign that USSR and the USA wanted to

develop ‘special relationships’.• Remember: Not all aid – vaccine or otherwise – distributed through

the WHO.• ‘Balancing factor’ – the Scandinavian vaccine production units,

which were allowed by their respective national governments to transfer vaccine production technologies

• Note - Danish help important in this regard in India

Variety in vaccine usage patterns

• Vaccine usage affected by global political trends and negotiations.

• Nationalism (in all quarters), and regional and local factors.

• There was competition between vaccine institutes based within South Asian nations.

• Disagreements between the Government of India, and UN agencies WHO and UNICEF (inter-UN disagreements as well)

Practical considerations• Local factors affected vaccinal usage patterns.• Infrastructure - for example, electrification & reliable

refrigeration.• Politics - local political and administrative backing for certain

training and working conditions.• Personnel - the difficulty in getting highly qualified workers to

settle in villages on a permanent basis.• Autonomy of local officials - often due to their alliances with

local politicians, who were often in opposition to the ruling party.

• Impact of social pressures on local officials.• All or many of these trends are often ignored – history/policy

assessments often tend to focus on policy/rhetoric (presented as the true condition in the field).

• Very few true studies of the complexities of policy implementation

Complex exchanges: Globally, internationally, regionally, nationally and locally!

• Is this an example of the ‘West’ dominating exchanges with the ‘East’? Not really.

• Many complexities: global-, international, regional-, national-, and provincial- local interactions.

• Between WHO and UN personnel, national government officials, donor bodies, and politicians of all shades.

• Indeed, we can see intermingling of ideas and working practices.

• Important example – the complexities of the ‘birth’, extension and actual form of surveillance-containment strategies.

Multi-faceted nature of resistance• The fear of vaccinal complications –

crucial component!• Articulated alongside religious &

other cultural concerns• Fear of losing caste/religion• Vegetarianism caused concerns

about a ‘cow-based’ vaccine.• Went hand in hand with refusal to

accept changes in vaccinal production methods relating to egg membranes.

• Pressure from local elites & politicians opposed to vaccination for a variety of reasons

• Fear of offending smallpox deities/demons

Future problems...disease mutation & vaccination itself

Diagnostic & structural problems….

A historian’s epilogue….• The difference between policy documents/rhetoric and actual

work/unfolding of policy deserves careful examination.• Important to examine the complex bases for ‘acceptance’/

‘compliance’.• Avoid the ‘science/rationality’ and ‘religion/irrationality’

dichotomy – things were & are always more complicated• People could believe in several remedies, often

taken/practised simultaneously.• Local vaccinators were, for instance, religious – vaccination

kits were often blessed at temples & shrines (entirely logical from their perspective).

• Consider widening our understanding of the process of prevention, rather than depending on narrow, medicalized notions.

Lessons for the future?• Community involvement important for all health

programmes – make individuals feel that ideas are being exchanged; that they are not being dictated by ‘outsiders.

• Makes internationalism all the more important – international co-operation in the field a gateway to open- mindedness.

• Open-mindedness amongst field personnel could allow for provision of insights into local intricacies; crucial for the adaptation and implementation of policy.

• Possible lessons for those involved in polio eradication – What is the true epidemiological position? How is the disease perceived by those targeted? What is actually being resisted?

• Possible lessons for the planned strengthening of PHC – What is the true PHC coverage? What needs re- organisation? Who are the local allies and stakeholders? Who assesses efficacy & what indices of success will be used?