The End of a Global Pox

From a public health perspective the disease of smallpox was officially declared eradicated in 1980 – the result of a successful global initiative led by the World Health Organization (WHO), the first and to date only success against a disease in humans. The world could celebrate its freedom from a dreaded disease. Much of the literature about the history of smallpox – a disease that has fascinated many writers – has finished on a triumphant note. From the first page of Bob Reinhardt’s book, however, it is clear that the author has a different focus. As his title indicates, this study is about America and smallpox eradication – ‘an effort led in large part by Americans’ (p. 14). Eradication is placed firmly in the historical context of the Cold War era, a lens that is the book’s strength, in that we need to be aware of how much the political context has dominated American policy and Americans’ view of the world. Furthermore, in this framework 1980 is not the end point of the smallpox story. Although discussing and celebrating eradication, Reinhardt looks to events and issues since then. From smallpox becoming a ‘suitable candidate for global eradication’ (chapter one), smallpox post-eradication is considered to be a ‘suitable candidate for global terror’ (chapter five).

The book begins with an exercise in the US about the reappearance of smallpox. Named Operation Dark Winter, the role-playing game was held in June 2001, and so before ‘9/11’, and involved senior personnel with military, political and medical backgrounds. Evoking the terror of smallpox in the past, the scenario outlines the spread and challenges of the disease, and the lack of sufficient vaccine for all the population. The main strategy, used in the Smallpox Eradication Programme (SEP), of ‘surveillance and containment’ is introduced. The Centers for Disease Control and Prevention (CDC) website today, however, makes it clear that it holds a stockpile of vaccine sufficient to vaccinate every American.(1) As Reinhardt comments, the scenario is oversimplified and melodramatic, but he uses it to make his point that today’s reality is that the smallpox virus remains – officially in laboratories in the US and Russia. Eradication, therefore, has set up a situation where smallpox remains a threat; and from a continuing American Cold War perspective where the threat comes from the Russian side of a world divide (p. 5).

By the middle of the 20th century smallpox was no longer a major public health problem in North America and Europe, but was still endemic in much of the rest of the world. For Americans, as an outbreak in New York in 1947 illustrated, smallpox was only a bus trip away – in this case Mexico (p. 19). The press exhorted Americans to become more proactive in a new global disease environment where air travel could now bring the diseases of Asia to New Yorkers. Internationally, malaria was considered to be a bigger health problem and, building on war-time success with the chemical DDT, became the health focus in US foreign policy to help the fight against communism. In this first chapter Reinhardt outlines how smallpox eradication gradually replaced malaria by the late 1950s as a global public health target; but without American support and finance the 1959 World Health Assembly initiative, proposed by the Soviet Union, remained underfunded and understaffed. Reinhardt attributes much of the blame to the US for the lack of progress in this period against smallpox (p. 56). Chapter two discusses how America also became committed to eradication. Drawing on a range of US archival sources and histories, support for international health programmes was a step towards achieving the Great Global Society, ‘a liberal effort to engage the decolonizing Cold War world’ (p. 53). The dreams of a world of universal rights and health, however, had disappeared by the time US President Lyndon Johnson, who had won a landslide election victory in 1964, gave his support to smallpox eradication at the end of 1965.

Although the US introduced the World Health Assembly proposal in 1966 that led to the establishment of a funded global eradication programme, America through its own CDC (then called the Communicable Disease Center) and USAID was finalising a bilateral smallpox and measles programme (SMP) in West and Central Africa. Over the previous few years since its establishment the CDC’s smallpox unit had been building its expertise and capacity. America had the technology to eradicate smallpox and Africa provided a further testing ground. The implementation of what increasingly became a smallpox eradication programme with measles a secondary activity, despite the wishes of host countries for whom measles was more of a problem, is the theme of chapter three, the central chapter literally and metaphorically of the book. With success against smallpox achieved in much of Africa, chapter four moves the story to New Delhi in 1972 and the start of the ‘final phase’ of the global eradication campaign. Success, Reinhardt explains, was envisaged to come with the ‘universal adoption of a discernibly American approach’ (p. 128) using the expertise and inspiration of enthusiastic personnel who had been in Africa. Instead, he continues, the American role stirred up Cold War resentments and postcolonial tensions with the result that the final phase took longer than hoped for and faced many challenges. A complex certification process followed before the Global Commission could conclude that smallpox had been eradicated.

Even before the end of chapter four the jubilation over eradication is tempered by the issue of what to do with the virus. Should it be destroyed or kept – and if retained, for what and where? For most of the campaign those involved focused on achieving eradication rather than on potential future dangers or further scientific research. The reader is thus led into chapter five which considers the immediate and ongoing post-eradication history and in America a rising climate of fear at the prospect of smallpox becoming a weapon of war and terror. The Dark Winter exercise that the book begins with encapsulates such American consciousness. The book finishes with an epilogue that reflects on smallpox eradication’s ‘Complicated Legacy’ (p. 190) – on the one hand the programme’s achievement and possible future campaigns against different diseases, but on the other its shortcomings as the virus remains in laboratories in the US and Russia.

With just 200 pages of text The End of a Global Pox: America and the Eradication of Smallpox in the Cold War Era is not a long book and inevitably it cannot be exhaustive. It reads easily, vividly conveying the dread aroused by smallpox of the past and a fear of the possible future. It draws on a range of sources and the chapter notes suggest the author has read widely, although it is a pity that more of these insights and discussion are not brought into the main text. From an international health perspective, the book’s strength is in presenting the story of America’s evolving commitment to smallpox eradication and showing the need to see health policies and programmes in a wider context. Little has been written about smallpox eradication in Africa and chapters two and three provide a welcome addition to the literature. Using a Cold War framework provides valuable insights into understanding international public health programmes and how they could – and often should - be viewed as an exercise in American soft power.

The Smallpox Eradication Programme (SEP) was actually somewhat anomalous in Cold War narrative terms, as it was a global programme built on collaboration rather than conflict. Reinhardt acknowledges this cooperation, but does not pursue the apparent irony. The WHO programme was led by Dr Donald A. Henderson, an American epidemiologist from CDC, but Henderson, with his small headquarters based in Geneva and limited funds, made a point of working through cooperation, at least publicly. Erez Manela suggests that the documentary record indicates a more ‘fraught and fragile’ relationship.(2) Manela’s article emphasises the importance of considering smallpox eradication in a Cold War environment but suggests that the WHO framework provided a ‘neutral space’ to carry out such projects (p. 322). At times, as Sanjoy Bhattacharya clearly brings out in his detailed study of smallpox and its eradication in India (3), the WHO organisation provided considerable challenges, such as the need for Henderson to convince senior personnel or the regional offices to support smallpox eradication or its preferred strategy. Nevertheless, Manela believes that the WHO was ‘indispensable’ to the success of the smallpox programme.

In chapter four Reinhardt moves from his central theme of American/CDC success in Africa to India in 1972 and the ‘final phase’ of the eradication campaign. Whereas in Africa the target was achieved within time, this next stage took longer than planned ‘in large part because global smallpox eradication was more than an American program’ (p. 136). In this new environment Americans and the American way were challenged. In the book’s introduction Reinhardt argues the need for more nuanced accounts of the eradication programme and that studies that have been done provide explanations that ‘complicate that picture of scientific heroism and suggest the myriad factors and historical contingency that led to smallpox eradication’ (p.13). His introduction notes refer to the ‘excellent’ work of Manela and ‘brilliant’ study of Sanjoy Bhattacharya. Yet the latter’s study of India only merits one note (no. 4) in chapter four at the end of a sentence that reads ‘Of course, Henderson and his staff could not assert total control of programme activities in the field’ (p. 125).

Disappointingly, chapter four is shorter and relies on a more limited range of documentary sources; perhaps evidence that the US considered their involvement with smallpox eradication in Africa the more important part of the global eradication story. After the end of the Second World War, however, India and Asia more broadly occupied a central position in international health. The statistics which Reinhardt draws from Frank Fenner and his co-authors’ massive official study of the eradication of smallpox (4) emphasise just how important India was in the global smallpox story. The number of reported cases in India in 1958 was 251,067 compared with 17,209 in Africa. Although smallpox was still endemic in India in 1972, one of the few remaining countries, starting the chapter in 1972 after the end of the US programme in Africa, suggests a narrative that progress was only really made when energetic and experienced Americans joined the campaign in. Bhattacharya’s study shows how much we need to move beyond seeing eradication in India as the product of the endeavours of outsiders. Henderson’s own account (5) also emphasises the complexities of the task of eradicating smallpox in India and the efforts already made, while Manela’s insights are important into understanding the WHO ‘space’ before as well as after 1972.

Another country where smallpox remained endemic in 1972 was Nepal. In a paragraph about the SEP adapting its strategy to local situations and reiterating that CDC emphasised the importance of such adaptation, Reinhardt gives the example of the SEP in Nepal abandoning year-round vaccination in 1971 to concentrate on the more acceptable cold winter months where people could stay at home and recuperate (p. 146). This was, nevertheless, still mass vaccination, although would then enable staff to concentrate on the preferred SEP strategy of containment and surveillance for the rest of the year. The WHO had been involved with the government in Nepal in smallpox eradication efforts since the early 1960s, with a further plan for an eradication project adopted in 1967 under the new global strategy. Although SMP CDC veteran Jay Friedman joined the programme as Operations Officer, this was in 1972 and so after the new strategy was introduced which Henderson acknowledged was a ‘surprisingly effective tactic in the eradication program’ (p. 185).(6) Despite the enormous challenges implementing any health programme in Nepal smallpox eradication was achieved; Henderson highlights success in Nepal to contrast with the struggles in India. Accounts from Nepal in the field also give no hint of Cold War rivalries. Earlier, in the 1963 smallpox epidemic in the Mt Everest region of Nepal New Zealander Sir Edmund Hillary writes of receiving vaccine sourced by WHO from Switzerland and Russia.(7) When there appeared to be problems with the Swiss vaccine Hillary’s team were quick to turn to what they considered to be the more powerful Russian vaccine. This last point also serves as a reminder that by far the biggest provider of vaccine for smallpox eradication globally was the Soviet Union.

In conclusion, this book is about America and smallpox eradication set in a Cold War context and as such it provides a valuable contribution to the literature; it tells us much about American views, the discussion taking place within the US about smallpox and CDC/USAID involvement with smallpox and measles in Central and West Africa. Its weakness, however, is the very American lens through which smallpox eradication is presented, with limited acknowledgement of the global programme, other countries or the work of non-Americans. I have concentrated this review, albeit only considering some countries, around the eradication of the disease for an important reason. Bob Reinhardt is right about the need for more nuanced accounts. We also need to not only have to rely on the vast and informative resource of the official study, compiled to be an instructive legacy of the programme. Smallpox eradication as a public health programme remains the one successful campaign in terms of getting rid of a human disease; it is still relevant for what it can tell us about such a process despite changing times. In a history with a longer timeframe or using another – however relevant – framework, such as the Cold War, there is a danger of the smallpox eradication campaign being absorbed into different narratives where health is no longer the prime focus. Examples like Nepal are also more likely to be overlooked or forgotten.

Notes

1. https://emergency.cdc.gov/agent/smallpox/vaccination/vaccine.asp.Back to (1)
2. Erez Manela, ‘A Pox on Your Narrative: Writing Disease Control into Cold War History’, Diplomatic History, 34:2 (2010), 299-323.Back to (2)
3. Sanjoy Bhattacharya, Expunging Variola: The Control and Eradication of Smallpox in India 1947-1977 (New Delhi: Orient Longman, 2006).Back to (3)
4. F. Fenner, D.A. Henderson, I. Arita, Z. Jezek and I.D. Ladnyi, Smallpox and its Eradication (Geneva: WHO, 1988).Back to (4)
5. D. A. Henderson, Smallpox: The Death of a Disease (New York, NY, 2009).Back to (5)
6. Ibid, p. 185.Back to (6)
7. Sir Edmund Hillary, Schoolhouse in the Clouds (London: Hodder & Stoughton, 1964).Back to (7)