The politics of smallpox eradication

EREZ MANELA

In May 1806, US president ThomasJefferson wrote a letter to EdwardJenner, the English physician who had discovered the smallpox vaccine a decade earlier. “Having been among the early converts, in this part of the globe, to its efficiency,” Jefferson wrote, “I took an early part in recommending it to my countrymen.” He continued:

I avail myself of this occasion of rendering you a portion of the tribute of gratitude due to you from the whole human family.

The discovery, Jefferson concluded, would ensure that “future nations will know by history only that the loathsome small-pox has existed.”^[201]

As it turned out, the US president was prescient if somewhat premature. It was only in 1977,171 years after that letter was written, that the last naturally occurring human smallpox infection abated. Why did it take so long? Part of the answer lies in technology. The global eradication of smallpox required techniques to manufacture vaccine on a vast scale and, even more impor­tantly, eradication had to await the advent of freeze-dried vaccine, which could be preserved and transported without need for refrigeration. Yet no less important for eradication were the developments in the theory and practice of international politics that occurred during those years. Global eradication required, first, the broad acceptance of the notion that disease control was properly a global, rather than local or national task. In addition, it required the development and operation of international organizations, namely the World Health Organization, which could serve as institutional platforms for such a mammoth undertaking.

Before vaccination: smallpox and its control to 1800

Smallpox, a deadly, infectious disease, had plagued humankind for millennia. Caused by the virus variola major, in its most typical form it killed some of 30-40 percent of its victims within weeks of infection. Survivors were often badly scarred, though they did acquire lifelong immunity. In many regions of the world the disease remained endemic for centuries, essentially a disease of childhood. But at other times and places it could also cause sudden, devastat­ing epidemics, hitting all segments of the population.^[202] It is hard to say with precision when smallpox first appeared, likely crossing over to human hosts from animal populations. There is evidence that suggests that smallpox afflicted the ancient Egyptians - Ramses V may have been a victim - and the disease can be positively identified in Chinese and Indian medical texts from the early Middle Ages. If, as John R. McNeill has recently argued, disease can be considered a historical agent when it has a differential impact on groups involved in a historical encounter, then smallpox played its great­est, most destructive role on the stage of history as probably the deadliest among the horde of Old World pathogens that crossed the Atlantic around the turn of the sixteenth century to decimate some 90 percent of the immunologically unprepared native populations of the Americas.^[203]

Techniques to induce immunity to smallpox by introducing the pathogen into the body in an attenuated form date to ancient times, and had been practiced across Asia and Africa for centuries before arriving in Europe. Some of these techniques involved harvesting dried smallpox scabs from victims of the disease, grinding them into a powder, and then introducing them into the body either through inhalation or by puncturing the skin.

The leading role assigned to Lady Mary has been challenged by some scholars, who note that similar practices were already prevalent among peasants in some parts of Europe decades before Lady Mary's discovery. Moreover, the practice was coming to the attention of other prominent figures in the Atlantic world at around the same time as it did to Lady Mary's, with interest driven at least in part by a spate of highly visible smallpox victims around the turn of the eighteenth century.^[205] For example, the Reverend Cotton Mather, the Puritan divine of Boston, first learned about inoculation in 1707 from African slaves and, after later reading, in the Transactions of the Royal Society of 1714, that the procedure had been for decades practiced among the Ottomans and “other Asiaticks," became a leading advocate of inoculation in New England when a smallpox epidemic broke out there in 1721. Mather, following his African interlocutors, described the procedure as “an Infallible Praeservative" that was “attended with a Constant Success," but it was fiercely controversial in Boston.

The demonstrated success in Boston - the death rate among the inoculated was 2 percent, compared to 14 percent or more among the unprotected - played a role, along with Lady Mary's advocacy and additional reports from Asia, in helping convince prominent persons in Britain to attempt it, and the Princess of Wales had her children inoculated in 1721.^[207] In the ensuing decades inoculation spread, albeit slowly, to other European courts, often following the smallpox-related deaths within royal families; by the 1770s it had been performed in royal courts in France, Russia, and a number of Scandinavian countries.^[208] The practice also spread among commoners in the course of the eighteenth century, but throughout it remained controversial. After all, it involved the introduction of the infective agent into a healthy body, with a 1-2 percent death rate among the inoculated. What's more, it quickly became clear that inoculated persons were contagious and could spread the illness to others for a number of weeks following the procedure. In any case, outside the royal houses precise data about the scale and efficacy of smallpox inoculation in Europe and elsewhere, and about its effect, if any, on demo­graphic trends, are sparse and inconclusive.^[209]

Vaccination: transnational spread and national politics in the 1800s

In 1796 an English country physician named EdwardJenner made a discovery that proved a crucial milestone in the control of smallpox, and eventually led to its eradication. The story is among the most famous in the annals of medicine. Jenner had noted that milkmaids seemed to have smooth skin, unblemished by the telltale scars of smallpox that were common in England at the time. He also noted that they often seemed to contract the much milder cowpox, a bovine version of the illness which, we know now, is caused by a virus similar but not identical to variola major.

In the ensuing decades the practice of vaccination spread across the world, moving across Europe and then the globe, following the pathways of com­merce and empire and tracing global networks of knowledge and power. In many ways the process paralleled the spread of inoculation in the previous century, except that it was more rapid and, perhaps more important, reversed in its direction. If in the case of inoculation Europeans were laggards, adopting only very late a practice that had been common in Asia and Africa for centuries, vaccination reversed the direction of flow, moving from its European - indeed, English - origins, to spread around the globe. Thus, nearly overnight inoculation was transformed from a technique at the cutting edge of medical progress that Europeans could learn from “Asiaticks” into a symbol of backwardness, an ancient and timeless “tradition” that had to be eradicated and replaced by its “modern” counterpart.

Given the unprecedented nature of Jenner's discovery, the spread of vaccination around the world was rapid. Indeed, within a decade the practice had spread across Europe and into the Russian and Ottoman empires. The Spanish court sent missions to carry vaccine material to its American possessions and from there across the Pacific to Manila.

As the practice of vaccination spread globally over the next century, the political valence of disease control was also changing, first from a local into a national issue and then into a global concern, thus making national politics, and later international politics, a central aspect of the process. It ^[211] was during this period that the control of disease also came to be viewed as an important governmental responsibility in the emerging nation states of Europe, both reflecting and shaping the wider state-building projects that sought to delineate and control national boundaries, and to render popula­tions more legible and productive.^[212] At about the same time as the emer­gence of national health regimes, international health regimes also came into being when successive cholera epidemics in Europe and North America prompted a series of conferences among the major powers, and generated international treaties that established and regulated international quaran­tine regimes.^[213]

But the quarantine regimes of the nineteenth century, though concluded in the international arena, still constructed disease control as primarily a national task, even as they instituted mechanisms of international co­operation to achieve it. The treaties, after all, aimed to help each government ensure that its own territory remained contagion-free rather than to control disease on a global scale. In this context, the prevalence of disease elsewhere, certainly outside Europe, was important only to the extent it could travel and endanger European populations or possessions. For smallpox to be eradi­cated, this perspective had to change.

The rise of global health

By the turn of the twentieth century, the growing acceptance of the germ theory of disease introduced a range of new methods of disease control. These new discoveries - most famously by Louis Pasteur in France and Robert Koch in Germany - were quickly implemented around the world, not least by colonial powers eager to make newly acquired tropical territories safe for their personnel and to highlight the “civilizing” effect of their rule. One of the best known of these programs was the campaign to control the mosquito-born diseases yellow fever and malaria in the Panama Canal Zone, whose success made the canal project possible and established the place of US Army surgeons Walter Reed and William Gorgas in the annals of public health. But the United States pursued disease control programs across its newly acquired overseas possessions, including in Cuba and the Philippines, as did other powers in their respective territories.^[214] At the same time the Rockefeller Foundation began to fund disease control programs abroad, largely in Latin America and in China. 1^[215] It was then that the idea of disease control as a global problem, rather than a national or even international one, began to take root, though even the Rockefellers did not yet attempt any­thing close to a global campaign.

The establishment of the League of Nations Health Organization (LNHO) after the First World War marked yet another stage in the rise of disease control as a field amenable to global action. LNHO leaders imagined their responsibilities as global, but with few resources at their disposal they could hardly put this notion into practice and thus largely focused on collecting information and developing international standards for medical practices - for example, for recording causes of death. The professional groupings that formed around the LNHO also began to cohere into an “epistemic commu­nity,” a network of public health experts whose interconnections and shared outlook laid the ground for the postwar establishment of the World Health Organization (WHO) and, more generally, the rise of the postwar global health establishment.^[216]

Despite the wide spread of vaccination in the nineteenth century, at the turn of the twentieth century smallpox was still endemic in much of the world. Even at mid-century, when more systematic vaccination had largely eradicated the disease in Europe and North America, it remained endemic in many parts of the Global South including South Asia, Sub-Saharan Africa, Indonesia, and Brazil.^[217] Thus, as the institutionalization of interna­tional health entered a new stage in the wake of the Second World War, the WHO emerged from the ashes of the LNHO much more ambitious than its predecessor. Its designation as a world organization reflected the global ambitions of its founders: it would serve not nations, but humanity itself.

But by the time the WHO's ambitious constitution was ratified in 1948 the Cold War was in full force. The Soviet Union and the other Eastern Bloc countries withdrew from the organization, suspicious of its intentions. This meant that the WHO's first major campaign, the ambitious effort to eradicate malaria that began in 1955, was largely a US-backed initiative. It had no Soviet participation and, moreover, it blatantly reflected US Cold War strategic concerns, focusing on regions, such as Southeast Asia, where Washington wanted to increase its influence, and slighting those, such as Africa, that were deemed less important.^[218]

Smallpox eradication as Cold War politics

In May 1958, Dr Viktor M. Zhdanov, Deputy Minister of Health of the Soviet Union, arrived in Minneapolis, Minnesota to attend the annual meeting of the WHO's governing body, the World Health Assembly (WHA). Reflecting Soviet premier Nikita Khrushchev's new policy of “peaceful coexistence” with the West, this visit marked the first time that a Soviet delegation had been sent to that forum since the establishment of the WHO ten years earlier. And Zhdanov made his mark, calling on the organization to launch a global campaign to eradicate smallpox, one of humankind's oldest and deadliest diseases. Mindful of the meeting's venue, he began his call with a quote from the letter that Thomas Jefferson had written to Edward Jenner more than a century and a half earlier. The time has come, he suggested, to fulfill Jefferson's prediction that “future nations will know by history only that the loathsome small-pox has existed.”

Zhdanov's call suggested that global eradication of smallpox be pursued using the methods that had previously worked in the Soviet Union. He proposed a five-year plan of compulsory vaccination of the entire population of endemic countries, though it allowed for accommodations in cases where compulsory vaccination was not feasible. The justification he offered for pursuing global eradication was a practical one, recognizing the world's growing interconnectedness and the global circulation of pathogens. The Soviet Union, though it had eradicated endemic smallpox, still counted hundreds of cases annually due to importations across its long borders with endemic countries such as Iran and Afghanistan. And with the growth of air travel, even those countries of the Global North that did not border endemic regions had to maintain costly vaccination programs to protect their popula­tions against importations. A co-ordinated global campaign, Zhdanov rea­soned, would cost much less than the indefinite continuation of such national vaccination programs.^[219]

The practical logic seemed unimpeachable, but the political context of the Soviet proposal complicated the US response. Since 1955, the WHO had been committed to the US-backed global Malaria Eradication Program (MEP).^[220] The smallpox proposal, then, was a Soviet move to seize the initiative in the international health field. Unsurprisingly, the United States, the WHO's largest donor, did not show much enthusiasm for the idea, and the WHA merely resolved to ask the WHO director general (DG) to prepare a report estimating what such a campaign would require, technically and financially.^[221]

The Soviet delegation continued to press for the program at subsequent WHA meetings, aided by the outbreak of a major smallpox epidemic in Pakistan in 1958. But the United States remained unsupportive, and, though the Assembly resolved to urge all endemic countries to launch eradication programs and asked the DG to provide assistance and collect data, it did not allocate any special funds for those purposes.^[222] So though smallpox eradica­tion was now officially a WHO priority, without US support the program existed largely on paper, with few funds and only a handful of staff. Its annual budgets ranged from US$100,000 to US$200,000, and it employed one med­ical officer who managed the program in Geneva and four field staff to cover all endemic regions, or much of the Global South.^[223] Each year at the WHA the Soviet delegation expressed its frustration with the slow pace of progress, pointedly contrasting the WHO's lackadaisical attitude to the SEP to its massive investment in the malaria eradication program, which was consuming a substantial proportion of the organization's budget.^[224] Within several years, however, the US government would reverse its position and decide to throw its support behind the SEP.

Pursuing eradication: from malaria to smallpox

By the early 1960s, it was becoming increasingly clear that the efforts at malaria eradication were fast approaching their limits, and that those limits lay well short of worldwide eradication.^[225] The program's basic approach sought to interrupt the transmission of the malaria parasite by targeting its mosquito vector through the use of synthetic residual insecticides, chief among them the ruthlessly efficient dichlorodiphenyltrichloroethane, or DDT. But the massive worldwide use of DDT spraying for malaria control since the Second World War had caused the proliferation of resistant mos­quito populations, and the more DDT was used the more prevalent resis­tance became. In addition, DDT had also come under attack for its environmental effects, as the massive decimation of insect populations reverberated up the food chain and disrupted ecosystems.^[226] Variola, on the other hand, had no animal vector. It moved directly from one individual to another through close contact, and so its eradication would not require a wider ecological intervention. Smallpox had other epidemiological advan­tages, too. There was a vaccine with a long history of effective use, few iatrogenic effects, and variola did not hide in animals, as the yellow fever virus did, or in asymptomatic individuals, as could happen with polio or tubercu­losis. Virtually all non-immune individuals who contracted the virus showed symptoms, and only they could transmit the virus to others.

As the prospects for the global eradication of malaria waned, epidemiolo­gists in the United States and elsewhere began to see smallpox as a more promising target for global eradication. And given the close connections of government officials in the health field with the professional communities and networks outside government - connections that relied on shared back­ground, educational experiences, and membership in professional associa­tions - it did not take long for the view to circulate. When James Watt, the director of the Office of International Health at the US Public Health Service, wrote in 1962 to fellow members of the American Public Health Association to solicit suggestions for eradication programs that the US health establish­ment should undertake, several proposed smallpox as the leading candidate for global eradication.^[227] Success, noted one member, would have significance for the global community much broader than itself:“We must face the cold sober fact that no communicable disease has ever been eradicated through­out the world to date through man's conscious efforts. It would certainly be a salutary thing to prove just once that one communicable disease can be eradicated through man’s conscious efforts. Smallpox is my nominee for such a global program.”^[228]

For the professional agreement on smallpox eradication to find traction, however, it needed to insert itself into the arena of international politics and have top political leaders bless the professional consensus with their support. The opportunity came in the early spring of 1965, with the approach ofWorld Health Day, marked each year on April 7, the anniversary of the founding of the WHO. With the MEP falling short of its goal of global eradication and the escalating war in Vietnam damaging the US reputation in the Third World, the Johnson administration was searching for new ways to display its com­mitment to international co-operation in public health. As it happened, the WHO had chosen for that year the theme of “Smallpox - Constant Alert,” advertised as a reminder for member governments to remain vigilant against the threat of the importation of the disease from the world’s endemic areas to regions where the disease had already been eradicated. Why not have the president, proposed an official from the Department of Health, Education, and Welfare (HEW), issue a statement for the occasion highlighting the success of smallpox control in much of the world - namely the Global North - and expressing US support for the WHO’s campaign to eradicate it globally? The White House agreed, and the statement proposed by HEW was released with only minor revisions.^[229]

The April statement was the first tangible indication of US support for the proposal that Zhdanov had made seven years earlier, and, though still vague in its terms, it laid the ground for a more specific commitment the following month. The United Nations had declared 1965, the twentieth anniversary of its founding, as International Cooperation Year (ICY) and the Johnson administration had been casting around for ways, preferably inexpensive, to show leadership in this field.^[230] ForJohnson and his advisers, then, smallpox eradication was exactly what the doctor ordered, a cheap, uncontroversial way to show US commitment to international co-operation. Therefore the World Health Assembly gathered for its annual meeting in Geneva in May, the White House announced on May 18, that “as long as smallpox exists anywhere in the world, no country is safe from it.” Summarizing the recently established expert consensus, Johnson asserted that the “technical problems” of global eradication were “minimal,” while the “administrative problems,” including assuring vaccine supplies, personnel, and co-ordination, could be solved through international co-operation. The United States, the statement concluded, was therefore “ready to work with other interested countries to see that smallpox is a thing of the past by 1975.”^[231]

Johnson's announcement gave few details as to what the United States would do and did not guarantee any resources. But the dramatic, public commitment from the president himself echoed widely and gave succor to supporters of the global eradication program. In Geneva, the US delegation announced the commitment to the WHA with some fanfare and reported with evident satisfaction that the assembly “displayed keen interest in the announcement”: The “presiding officer expressed deep appreciation for president's statement” and the WHO Deputy DG later congratulated the US delegates on the announcement's “ideal timing and content.”^[232] Within a few days, US representatives in endemic countries, prodded by American epidemiologists on the ground, began to propose ways of putting the commitment into effect. Integrating smallpox vaccination into ongoing US-supported health programs, wrote one, presented a “tremendous opportunity for dramatizing” the president's pledge to support smallpox eradication worldwide.^[233]

In the domestic politics arena in the United States, however, the rhetoric of international co-operation had its limits. While Johnson described the US decision to support the SEP and other international health initiatives as a move toward transcending Cold War conflicts, US officials justifying such programs domestically often reverted to the traditional rhetoric of Cold War rivalry, presenting them as an antidote against the spread of communism among the world's poor and downtrodden. Such assistance was “a tool” which could “penetrate any Iron or Bamboo curtain to reach the minds and the hearts of man.” It would promote world peace, showcase the United States as “the fountainhead of medicine,” and help US allies combat the temptations of communism.^[234] US support for the SEP, then, could have conflicting justifications for different audiences. For the international community and domestic internationalists, it was about transcending the Cold War. To hardline anti-communists, it could be about winning it. In this view, in working with the USSR on smallpox eradication the United States would enlist the Soviets to assist in their own demise.

The politics of vaccine manufacture

For those who needed to carry out the task, however, political considera­tions of a wholly different sort took precedence. For one, the SEP required vast quantities of vaccine - more than 2 billion doses, it turned out - and only the USSR initially had the necessary infrastructure in place to produce that many doses, because Western manufacturers had found smallpox vaccine unprofitable to make.^[235] So when Donald A. Henderson, the Ohio-born physician who was chief of the Epidemic Surveillance Section of the US Public Health Service's Communicable Disease Center (CDC) in Atlanta, moved to Geneva to head the program, his first priority was to ensure that Soviet vaccine donations to the program would continue.^[236] His position was none too comfortable. The Soviets had initially been unhappy with his appointment, protesting that the SEP had been a Soviet initiative and so a Russian should have been appointed to lead it. So the following May, when Henderson approached the head of the Soviet

delegation, Dmitry Venediktov, during the WHA meeting, to request that the vaccine donations continue, he recalls being somewhat apprehensive. But the Russian explained that, though he could not officially guarantee vaccine donations more than one year at a time, the nature of the Soviet planned economy was such that once a certain annual production quota was in place it was likely to be reliably met each year.^[237]

For the next decade, Henderson continued to place great importance on preserving good relations with the Soviets and worked assiduously to nurture the collaboration. Throughout his time as program head he was careful to give the Soviet Union credit for initiating the program. He also worked closely with Russian officials to resolve problems, for example with the quality of Russian vaccine, in a way that avoided any public embarrassment for the Russians. Any issues with the Soviets, he instructed his WHO colleagues, were to be “resolved quietly” and should “not be openly dis­cussed” so as to avoid straining the relationship.^[238] Before each year's WHA, Henderson met with both the US and the Soviet delegation to report on the program's progress, and relied on them to keep the issue on the agenda. Henderson also relied on the help of American and Soviet diplomats posted in endemic countries to exert pressure on health officials, whether at WHO regional offices or in national health bureaucracies, who were deemed insufficiently co-operative with the program. Henderson worked with Soviet counterparts to establish and maintain quality controls for Soviet vaccine production and to vet Russian candidates for program positions. Finally, the Moscow Research Institute for Viral Preparations shared respon­sibility with the CDC lab in Atlanta for advanced analysis of specimens taken in the field.^[239]

In the end, this much is clear: without the combination of US funding and Soviet vaccine, and without the institutional momentum and political sup­port that the two superpowers provided for the program, the SEP could not have gotten off the ground, much less found success. Of the program's total US$98 million price tag, about a third came from the budget of the WHO and other international organizations, to which the United States was the leading donor; Washington also contributed an additional US$25 million in direct payments to the program account.^[240] This was, to be sure, small change in comparison to US military spending during the same period. It was even much less than had been spent on the malaria eradication program. But it was nevertheless crucial for the SEP's success. The Soviet Union, on the other hand, contributed the lion's share of the vaccine; nearly 1.7 billion doses altogether out of the roughly 2 billion used in the course of the global eradication efforts.^[241]

Into the field: negotiating “tradition” and resistance

Even with the Cold War superpowers locked in competitive collaboration, how was it possible to vaccinate billions of individuals across dozens of nations and in some of the world's most impoverished, inaccessible regions? One of the SEP's de fining characteristics, after all, was the application of homogenizing, modern scientific knowledge on a diverse array of local practices in the Global South, where many communities already had long­standing practices intended to ameliorate and explicate the encounter with smallpox. Indeed, the standardization of such things as vaccine production and quality, vaccination techniques, and methods of epidemic surveillance and control stood at the center of the program's raison d’etre and constituted for its leaders a sine qua non of global eradication.

Thus, in various regions, SEP personnel, in conjunction with national and local health officials, had to contend with long-standing modes of dealing with smallpox that integrated the illness into elaborate indigenous belief systems and medical practices. In parts of West Africa, for example, this meant negotiating the co-operation or acquiescence of priests of the smallpox “fetish” Sopona. By far the largest consumer of SEP vaccine was the Indian subcontinent, but here the program had to contend with the worship of the smallpox deity Sitala mata and the practices associated with it.^[242] Meanwhile, in rural Afghanistan SEP vaccinators had to find ways to work around purdah practices that rendered access to women and children difficult.^[243] They also had to get practitioners of the long-established method of variolation to cease their practice or else trade their powdered-scab material for SEP-supplied vaccine, efforts that included legislation and enforcement, community out­reach, and even the circulation of appropriate morality tales such as one entitled “A variolator gives up his profession and encourages his son to become a vaccinator.”^[244]

The absolute nature of the program’s goal - smallpox was to be not simply controlled but entirely eradicated worldwide - meant that any resistance to its homogenizing requirements had to be overcome, either negotiated away or, if necessary, broken. Pressure on individuals who resisted vaccination took various forms: insistent verbal persuasion, the application of social and legal pressure, offers of payment, and, at the extreme, forcible vaccination con­ducted through military-style raids. In one well-known example, a top inter­national SEP official in India later recalled how he had led a team of vaccinators that, accompanied by Indian military troops, broke in the dead of night into the home of a tribal leader in a remote village located in what was then southern Bihar state. The man believed it was his religious duty to resist vaccination. He was subdued and vaccinated only after a violent struggle, after which he agreed to allow the vaccination of the other inhabitants of the village.^[245]

While vaccination using physical force was atypical, various degrees of resistance shadowed the program in many regions. Early assumptions that resistance was the result of “traditional” beliefs opposed to modern science proved shaky as studies found that such beliefs did not correlate well with resistance to vaccination. Rather, it was often the association of vaccination campaigns with the exercise of power by the government or outsiders that explained suspicion of the program, especially in relatively isolated areas where residents associated government officials on the scene with taxation, conscription, or other predations and were generally suspicious of the inten­tions and motives of outsiders.^[246] Henderson himself professed to dismiss the problem of resistance, opining to an Indian colleague that “most of the stories of resistance” were born “in the minds (or perhaps the backsides) of indolent Health Officers... who would rather sit than walk and need a convenient excuse to explain why people aren't vaccinated.”^[247] But reports from the field were not quite so sanguine. One SEP training manual in India explained that resistance was “usually relative rather than absolute and therefore, an atti­tude of persistence must be developed by the containment team,” and added ominously that persons refusing vaccination should be reported to higher authorities.^[248]

On the whole, however, resistance to the SEP took the form of individual acts of defiance and was neither well organized nor particularly widespread. Nowhere across the vast and varied terrain of the program did it encounter a broad anti-vaccination movement, though such movements had been common in North America and Europe in earlier decades and also occurred in India, against tuberculosis immunization, in the 1950s.^[249] The story of the SEP, therefore, is not simply one of local resistance to external authority, whether national or international. It is also one of accommodation, acquies­cence, and collaboration, North-South as well as East-West. After all, the international officials and experts who ran the program could not have carried it out absent the co-operation of innumerable individuals in en­demic countries on all levels of society, and the vast majority of SEP fieldworkers, more than 150,000 health personnel all together, were drawn from the local populations.^[250]

In part due to such local integration, the program displayed unusual flexibility in adapting its methods to local conditions, whether political, administrative, epidemiological, or cultural. When, soon after it was launched, the goal of 100 percent vaccination proved impractical, the program moved quickly to focus on “surveillance and containment,” an eradication method that sought to identify outbreaks early and concentrate on vaccinating those living within a certain radius around them in order to prevent transmission beyond the outbreak area.^[251] The SEP proved resilient enough to survive the bloody civil wars that erupted in some of its main regions of operation, including Nigeria, Bengal, and the Horn of Africa, often negotiating access to conflict zones with the various state and non-state parties involved. Finally, unlike many of the projects that popu­late the historiography of international development in the Cold War era, the SEP succeeded in achieving its goal, reaching “smallpox zero” world­wide by the end of 1977, only two years beyond the timeframe that Johnson had set in 1965.

The SEP and the politics of global health

The eradication of smallpox has often been celebrated in retrospect as the WHO's crowning achievement. But the common narrative of triumph obscures the fact that the program faced strong opposition for many reasons and from many quarters within the organization throughout its life. For one, top WHO officials, including its longtime director general, the Brazilian epidemiologist Marcolino Candau, were notably unenthusiastic about the program early on. Candau, who was WHO DG from 1953 to 1973, was a malariologist who had studied public health at Johns Hopkins University and cut his epidemiological teeth in the anti-malaria campaigns in South America.^[252] He saw the MEP’s failure to achieve eradication as a serious blow to the WHO’s credibility, and worried that a failed attempt to eradicate smallpox might deal the organization’s reputation a further blow. After all, leading figures in the scientific community at the time held that programs aiming at the complete eradication of any infectious disease were impractical for a host of biological, political, economic, and social reasons. Such programs, one prominent expert argued in a widely read book at the time, reflected the hubris of modern man. They were little more than another type of social utopia and were destined for an end even more ignominious than the dustbin of history, namely as “a curiosity item on library shelves.”^[253]

When the members of the WHA unanimously resolved, in May 1965, that the global eradication of smallpox was a “major objective” of the organization, top WHO officials tried to stall.^[254] On the one hand, they could not disregard the assembly's instructions. On the other, they sought to keep the program at arm's length and make sure it did not embarrass the organization or derail its priorities. The following spring, when Candau submitted his proposed budget for 1967, he requested a sum of US$2.4 million for the smallpox eradication program, a 16 percent increase in the organization's total budget over the previous year, far larger than usual. When the representatives of the rich nations complained, as expected, that the increase was too steep, Candau gamely offered to cut the proposed SEP budget. The message was clear: the program was not an important priority for the organization. If the rich nations insisted on it, they would have to pay.^[255] The DG may have viewed his budget request as a negotiating tactic, but representatives from the Global South chose to take it at face value. In the contentious discussion that followed, the proposal, including the full US$2.4 million sum for the SEP, passed by the slimmest of margins, on the strength of votes from Third World nations.^[256]

Even after the budget's passage, many WHO officials, especially in the all­important regional offices where much of the practical work was to be done, remained skeptical of the program.^[257] Many wanted the organization to focus on basic health care and therefore viewed the narrow focus of the SEP with a degree of suspicion; they often saw it as a lower priority, even a distraction, from the central goal of developing the capacity to deliver basic health services.^[258] From this perspective, the apparent success of the SEP by the mid-1970s only compounded the problem. In the late 1970s, even as the WHO worked on certifying the achievement of “smallpox zero,” the organization moved to emphasize the importance of “horizontal” health interventions over “vertical” programs such as the SEP. “Vertical” programs were ones that targeted one specific health problem for elimination, while “horizontal” interventions aimed for a broad transformation of health care services in developing countries, emphasizing preventive and primary health care ser­vices provided in a context sensitive to the underlying economic, social, and cultural factors at play.^[259]

These tensions within the international health establishment came to a head in 1978, just as the SEP was coming to a successful close, when WHO members gathered in Alma-Ata, capital of the Kazakh Soviet Socialist Republic, to mark the organization's thirtieth anniversary. The conference culminated in a major declaration that set ambitious goals. It reaffirmed the broad definition of “health” in the WHO constitution as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity,” and set for the organization the ambitious goal of achieving “health for all by the year 2000."^[260]° The Alma-Ata Declaration, viewed as a landmark in the evolution of the organization's commitment to the horizon­tal approach, defined the goal as the provision of primary health care to all of the world's population.^[261] For supporters of such goals, the success of global smallpox eradication was liable to be a distraction, encouraging focus on narrowly technical interventions at the expense of the broader programs envisioned by the declaration.

Despite such ambivalence toward the SEP, however, the WHO was also essential to the program in all its stages, from conception to execution. The institutional framework of international governance and co-operation that the WHO provided gave health officials in the United States and elsewhere a space within which they could conceive and articulate smallpox eradication as a global problem that required a co-ordinated global solution, and then to pursue it as such. Prior to the emergence of international institutions, after all, international health meant little more that treaties on quarantine regula­tions, which constructed disease control as a national problem requiring defensive measures that reinforced the inviolability of national boundaries rather than a worldwide problem necessitating co-ordinated action on a global scale.^[262] The collaborative superpower relationship that defined the program, moreover, would have been unlikely absent the neutral space provided by the WHO framework, one that allowed the bracketing of Cold War political and ideological rivalries and thus made room for acting on a shared discourse of high modernist progress. If the WHO as an organization was sometimes an obstacle that the SEP had to overcome, as a symbolic and collaborative space it was indispensable.

Conclusion

After three years of a rigorous certification process, the World Health Assembly gathered in Geneva in May 1980 and issued an official proclamation announcing to the world the global eradication of smallpox. Since then, the variola virus has remained stored in two recognized repositories in the United States and Russia and, possibly, in unofficial ones elsewhere, and has been the subject of a contentious debate as to whether it should be entirely destroyed or preserved for future scientific research.^[263]

The eradication of smallpox was facilitated by an unusual, perhaps unique convergence of factors that existed in international society from the mid- 1960s to the mid-1970s. In the wake of the Cuban Missile Crisis, the two superpowers had entered an era of detente. At the same time, rapid decolonization fostered competition over the “hearts and minds” of newly independent peoples, competition that could, in the right circumstances, turn into collaboration when both sides wanted to be seen as doing something for the world's poor, and neither was willing to abandon the promising arena of the SEP to the other. This period also saw a high point in the legitimacy and activity of the UN specialized agencies such as the WHO, a “golden age” of sorts that began with the Russian re-engagement in the late 1950s and came to an end with the US disengagement two decades later under the influence of the rising neoliberal wave. Public health professionals craved a dramatic achievement that would bolster their authority, and they won political backing by proposing smallpox as a uniquely eradicable scourge and the SEP as an inexpensive way for the two superpowers to demonstrate their developmental bona fides.

In the decades since, the SEP has become widely viewed and represented as the paradigmatic success in the history of disease control. No other major infectious disease of humans has been entirely eradicated (though the global eradication of rinderpest, an infectious disease of cattle, was achieved in 2001 and officially certified in 2011). But the meanings and implications of the SEP's success have remained contested within the global health community and beyond. Was it a model for the eradication of the many other infectious diseases - polio, tuberculosis, malaria, yellow fever, perhaps even AIDS - that still plague humanity? Or was it a singular event, made possible by the unique epidemiological characteristics of smallpox - the existence of a foolproof vaccine, the lack of asymptomatic carriers, the lack of an animal reservoir - or by the specific confluence of international conditions of the 1970s, such as the Cold War-driven competitive collaboration among the superpowers, and a highpoint in the status and efficacy of international organizations?

Moreover, even if the success of the SEP could be repeated with other diseases - and, as these lines are written, the poliomyelitis virus may well be on the verge of global eradication - what of the horizontalist critiques, along the lines of the Alma-Ata Declaration of 1978, that argue that the focus on the eradication of individual pathogens is in any case misguided and should take a back seat to broader efforts to improve the health of the world's poor, most especially the broad-based improvement in the delivery of primary health care? Thomas Jefferson's 1806 prediction has now been fulfilled, even if it took much longer than he seems to have anticipated. But the debates that swirled around the SEP in its time are still very much with us, and they are, to a significant extent, political debates, centered on the appropriate distribution of scarce resources. Even with the variola virus gone from the natural world, understanding the history and the politics of smallpox eradication remains as crucial as ever.

Further reading

Albert, Michael R., Kristen G. Ostheimer, and Joel G. Breman. “The last smallpox epidemic in Boston and the vaccination controversy, 1901-1903.” New England Journal of Medicine 344:5 (February 2001), 375-379.

Anderson, Warwick. Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines. Durham, nc: Duke University Press, 2006.

Baldwin, Peter. Contagion and the State in Europe, 1830-1930. Cambridge University Press, 1999.

Birn, Anne-Emanuelle. Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico. Rochester, ny: University of Rochester Press, 2006.

Bowers, John Z. “The odyssey of smallpox vaccination.” Bulletin of the History of Medicine 55:1 (Spring 1981), 17-33.

Clendenning, Philip H. “Dr. Thomas Dimsdale and smallpox inoculation in Russia.” Journal of the History of Medicine and Allied Sciences 28:2 (April 1973), 109-125.

Crosby, Alfred W. The Columbian Exchange: Biological and Cultural Consequences of 1492. Westport, cτ: Greenwood, 1972.

Cueto, Marcos. Missionaries of Science: The Rockefeller Foundation and Latin America. Bloomington, in: Indiana University Press, 1994.

Dixon, Cyril William. Smallpox. London: J. & A. Churchill, 1962.

Eriksen, Anne. “A case of exemplarity: C. F. RottbolTs history of smallpox inoculation in Denmark-Norway, 1766.” Scandinavian Journal of History 35:4 (December 2010), 351-370.

Farley, John. To Cast out Disease: A History of the International Health Division of the Rockefeller Foundation, 1913-1951. Oxford University Press, 2004.

Glynn, Ian, and Jenifer Glynn. The Life and Death of Smallpox. London: Profile Books, 2004.

Goodman, Neville M. International Health Organizations and Their Work. London: J. & A. Churchill, 1952.

Greenough, Paul. “Intimidation, coercion and resistance in the final stages of the South Asian smallpox eradication campaign, 1973-1975.” Social Science & Medicine 41:5 (1995), 633-645.

Herbert, Eugenia W. “Smallpox inoculation in Africa.” Journal of African History 16:4 (1975), 539-542.

Howard-Jones, Norman. International Public Health Between the Two World Wars: The Organizational Problems. Geneva: World Health Organization, 1978.

“Origins of international health work.” British Medical Journal 1 (May 1950), 1032-1046.

The Scientific Background of the International Sanitary Conferences, 1851-1938. Geneva: World Health Organization, 1975.

Lee, Sung. “WHO and the developing world: the contest for ideology.” In Andrew Cunningham and Bridie Andrews, eds., Western Medicine as Contested Knowledge. Manchester University Press, 1997, pp. 24-45.

Litsios, Socrates. “Malaria control, the Cold War, and the postwar reorganization of international assistance.” Medical Anthropology 17:3 (1997), 255-278.

“The long and difficult road to Alma-Ata: a personal reflection.” International Journal of Health Services 32:4 (2002), 709-732.

Marglin, Frederique Apffel. “Smallpox in two systems of knowledge.” In Frederique Apffel Marglin and Stephen A. Marglin, eds., Dominating Knowledge: Development, Culture, and Resistance. Oxford: Clarendon Press, 1990, pp. 102-144.

McMillen, Christian W., and Niels Brimnes. “Medical modernization and medical nationalism: resistance to mass tuberculosis vaccination in postcolonial India, 1948­1955.” Comparative Studies in Society & History 52:1 (January 2010), 180-209.

McNeill, John R. Mosquito Empires: Ecology and War in the Greater Caribbean, 1620-1914. Cambridge University Press, 2010.

Miller, Genevieve. “Putting Lady Mary in her place: a discussion of historical causation.” Bulletin of the History of Medicine 55:1 (Spring 1981), 2-16.

Packard, Randall M. “Visions of postwar health and development and their impact on public health interventions in the developing world.” In Frederick Cooper and Randall M. Packard, eds., International Development and the Social Sciences. Berkeley, ca: University of California Press, 1997, pp. 93-118.

Razzell, Peter. The Conquest of Smallpox: The Impact of Inoculation on Smallpox Mortality in Eighteenth Century Britain. Firle: Caliban Books, 1977.

Roberts, Shirley. “Lady Mary Wortley Montagu and the Reverend Cotton Mather: their campaigns for smallpox inoculation.” Journal of Medical Biography 4:3 (August 1996), 129-136.

Siddiqi, Javed. World Health and World Politics: The World Health Organization and the UN System. London: C. Hurst, 1995.

Tucker, Jonathan. Scourge: The Once and Future Threat of Smallpox. New York: Grove Press, 2001.