Sanjoy Bhattacharya

The World Health Organization and global smallpox eradication

Background: This article examines the multifaceted structures and complex operations of the World Health Organization and its regional offices; it also reassesses the form and the workings of the global smallpox eradication programme with which these bodies were closely linked in the 1960s and 1970s. Methods: Using the case study of South Asia, it seeks to highlight the importance of writing nuanced histories of international health campaigns through an assessment of differences between official rhetoric and practice. Results and conclusion: The article argues that the detailed examination of the implementation of policy in a variety of localities, within and across national borders, allows us to recognise the importance of the agency of field managers and workers. This analytical approach also helps us acknowledge that communities were able to influence the shape and the timing of completion of public health campaigns in myriad ways. This, in turn, can provide useful pointers for the design and management of health programmes in the contemporary world.

A TALE OF TWO GLOBAL HEALTH PROGRAMS Smallpox Eradication's Lessons for the Antipolio Campaign in India

India provided one of the most challenging chapters of the worldwide smallpox eradication program. The campaign was converted from a project in which a handful of officials tried to impose their ideas on a complex health bureaucracy to one in which its components were constantly adapted to the requirements of a variety of social, political, and economic contexts. This change, achieved mainly through the active participation of workers drawn from local communities in the 1970s, proved to be a momentous policy adaptation that contributed to certification of smallpox eradication in 1980. However, this lesson appears to have been largely forgotten by those currently managing the Global Polio Eradication Initiative. We hope to show ways in which contemporary efforts to eliminate polio worldwide might profitably draw on historical information, which can indicate meaningful ways in which institutional adaptability is likely to help counter the political and social challenges being encountered in India.

The local bases of global public health: complexities and opportunities

Historically, the big divide in international and national public health circles has been between the supporters of “vertical” and “horizontal” programmes. Advocates of the vertical approaches have highlighted the usefulness of targeting one disease at a time, through concerted political and social action, with the ultimate goal of eradication. Their opponents, on the other hand, have highlighted the significance of horizontal services, which can be described most easily as the health networks that cater for patients on a day-to-day basis (such as public hospitals, primary health care centres, dispensaries, travelling maternal and childcare services). Both groups have had powerful spokespeople, who have drawn on specific examples to strengthen their arguments; they have, similarly, quoted cases to underline the weaknesses of the other party. These debates have, by and large, been accusatory – each side has blamed the other for weakening, sometimes beyond repair, working models of their health-care plans. Yet, interestingly, these debates have been – and continue to be – carried on the basis of theoretical ideals and models. Put another way, disjoints between theory and practice have generally not been studied in any detail, which has meant that meaningful reforms have been difficult to implement. The result, according to many observers, is a situation where debates and discussions within organizations like the UN, WHO, United Nations Children’s Fund (UNICEF), the World Bank and the International Monetary Fund (IMF) have historically been ideologically predetermined, with relatively very little knowledge about the localities where the health projects are being or will be targeted. There is, as a result, much space to rethink the theories and the practical intricacies of public health. The acts of identifying disease/s, the calculation of costs inflicted by it/them, the selection of preventive strategies and cures, and, not least, their introduction in different social settings are not value-free processes. To the contrary, all biomedical concepts, products and services are intensely political and social phenomena, where different interest groups, complex market forces and ideologies interact, compete or combine to create a multiplicity of situations. Historians and other social scientists are very well placed to assess these conditions, as they existed in specific regions, countries and localities, over a protracted period of time. Such information can be invaluable to those seeking to develop and apply context-specific public health policies. Historical studies can also help in another way: independent and critical assessments of past global health programmes can provide important pointers for the future, if, of course, one is able to convince those currently involved in managing similar projects. For instance, the doomed malaria eradication campaign, which is generally accepted as a classic “vertical programme”, has important warnings to offer the managers of the global polio eradication initiative – overarching policies designed by a handful of officials cannot be forced upon diverse national and local governments and societies. Should we be looking for new, more lasting solutions? One fruitful strategy might be to convince policy-makers and field workers that it is possible and useful to interlink vertical and horizontal programmes. After all, varying levels of integration are already visible in the field in national contexts where disease control and eradication programmes have been systematically introduced. The strengthening of routine rural health services can contribute to social well-being as well, especially if reliable networks of maternal and child care are made a central element of these delivery systems. Facilities for the immunization of newborns and infants, whose exact form would depend on the disease profiles of the regions that they were serving, would be a significant component, as this has shown to be an effective means of winning the support of mothers and grandmothers (who play an incredibly important role in determining the success of health-care schemes). The history of global smallpox eradication provides us with another important lesson – the need to develop flexible vertical health programmes, based on partnerships with communities at which they are being targeted. Such exercises in adaptive verticality would help in the early identification of potential social, cultural and political challenges in a diversity of localities, and then allow for the design and implementation of nuanced and effective policy. Apart from anything else, this would allow the target groups to behave like responsible stakeholders and help dispel notions of the forcible, top-down imposition of health-care strategy, which is widely disliked in almost every national context in which WHO officials are active. If put into practice, the strategy of adaptive verticality can contribute in another very meaningful way in the long term – it will allow the managers of vertical health programmes, which have powerful supporters within national governments and international agencies (and are, therefore, unlikely to be discontinued in any context) to work efficaciously with political constituencies, government health personnel and WHO officials supportive of the worldwide reinvigoration of an organized strategy of primary health care. ■

Uncertain advances: a review of the final phases of the smallpox eradication program in India, 1960-1980.

In this article, I describe the complex nature of the final phases of the Indian smallpox eradication program. I examine the unfolding of policies at different levels of administration and the roles played by a wide range of national and international actors. A careful examination of unpublished official correspondence, on which this article is largely based, shows that the programs managers were divided and that this division determined the timing of the achievement of eradication. This material also reveals that Indian health workers and bureaucrats were far more capable of reshaping policies in specific localities, often in response to local infrastructural and political concerns, than has been acknowledged in the historiography.

Struggling to a monumental triumph: re-assessing the final phases of the smallpox eradication program in India, 1960-1980

The global smallpox program is generally presented as the brainchild of a handful of actors from the WHO headquarters in Geneva and at the agencys regional offices. This article attempts to present a more complex description of the drive to eradicate smallpox. Based on the example of India, a major focus of the campaign, it is argued that historians and public health officials should recognize the varying roles played by a much wider range of participants. Highlighting the significance of both Indian and international field officials, the author shows how bureaucrats and politicians at different levels of administration and society managed to strengthen--yet sometimes weaken--important program components. Centrally dictated strategies developed at WHO offices in Geneva and New Delhi, often in association with Indian federal authorities, were reinterpreted by many actors and sometimes changed beyond recognition.

International health and the limits of its global influence: bhutan and the worldwide smallpox eradication programme.

Histories of the global smallpox eradication programme have tended to concentrate on the larger national formations in Africa and Asia. This focus is generally justified by chroniclers by the fact that these locations contributed a major share of the world’s annual tally of variola, which meant that international agencies paid a lot of attention to working with officials in national and local government on anti-smallpox campaigns in these territories. Such historiographical trends have led to the marginalisation of the histories of smallpox eradication programmes in smaller nations, which are presented either in heroic, institutional tropes as peripheral or as being largely shorn of sustained campaigns against the disease. Using a case study of Bhutan, a small Himalayan kingdom sandwiched between India and China, an effort is made to reclaim the historical experiences in small national entities in the worldwide smallpox eradication programme. Bhutan’s experience in the 1960s and 1970s allows much more in addition. It provides us with a better understanding of the limited powers of international agencies in areas considered politically sensitive by the governments of powerful nations such as India. The resulting methodological suggestions are of wider historical and historiographical relevance.

A Secure Future

Medical History is embarking on an exciting new journey. Thanks to the Wellcome Trust, the ownership of this journal has passed to Cambridge University Press. The Press is committed to running the publication as its flagship journal in the history of medicine, related sciences and health, and is keen to offer authors full flexibility when it comes to publishing and archiving their articles. Medical Historys editorial office has moved to the Centre for Global Health Histories at the University of York, which is housed within its Department of History; the Centre and Department are honoured to be associated to this world-leading journal.

Multifaceted contributions: health workers and smallpox eradication in India

Smallpox eradication in South Asia was a result of the efforts of many grades of health-workers. Working from within the confines of international organisations and government structures, the role of the field officials, who were of various nationalities and also drawn from the cities and rural enclaves of the countries in these regions, was crucial to the development and deployment of policies. However, the role of these personnel is often downplayed in official histories and academic histories, which highlight instead the roles played by a handful of senior officials within the World Health Organization and the federal governments in the sub-continent. This article attempts to provide a more rounded assessment of the complex situation in the field. In this regard, an effort is made to underline the great usefulness of the operational flexibility displayed by field officers, wherein lessons learnt in the field were made an integral part of deploying local campaigns; careful engagement with the communities being targeted, as well as the employment of short term workers from amongst them, was an important feature of this work.

A Strong Field and a Deserving Winner

Medical History is delighted to announce the winner of the 2014 William Bynum Prize: Clare Leeming-Latham’s wonderful essay titled ‘Unravelling the “tangled web”: Chemotherapy for Tuberculosis in Britain, 1940–70’. We are also pleased to announce a set of joint runners up: Elisa Gonzalez (‘Nurturing the Citizens of the Future: Milk Stations and Child Nutrition in Puerto Rico, 1929–60’) and Anne Hanley (‘Venereology at the Polyclinic: Postgraduate medical education among general practitioners in England, 1899–1914’). The prize committee was chaired by Professor William Bynum, and also included Professor Alison Bashford, Dr Joanna Radin, Professor Andrew Scull and Dr Laurence Totelin. We had an extraordinarily strong field. Out of the eleven entries, six are showcased in this issue (these essays sit alongside the piece by Katherine A. Walker, who was a runner up in the 2013 Bynum Prize competition). Based on the reports received, a further four entries submitted in 2014 have been asked to revise and resubmit for potential future publication. Only one essay did not meet the standard required for publication. Our congratulations to all these young scholars – all of us, Professor Bynum included, were impressed with the range of tremendous work on display.

Polio eradication in Syria

www.thelancet.com/infection Vol 14 July 2014 547 capacity for life. Put another way, polioviruses maintain themselves by seeping through the boundaries—real or imagined—we use to contain them. In view of this, we need a more cautious approach to our thinking, and might need to reduce our expectations of global eradication eff orts. New strategies for understanding disease are needed. We need to be more vigilant about infectious disease virology and epidemiology, even as the world seems to be shifting from societies dominated by infectious diseases to societies dominated by chronic ones. We can no longer assume that vaccinated or unvaccinated bodies in one place will all respond similarly to viruses, even when we account for statistical risks, herd immunity, and people who are immunocompromised. We have to appreciate that vaccination eff orts are mediated by not only biomedical reasoning but also politicoeconomic and sociocultural processes. We must recognise that our global ecologies and geopolitical realities are so highly integrated that viruses, such as polio, can take advantage of this integration to survive. Polioviruses’ adaptive capacities already outstrip the pace of intervention—since we have been able to see them they have probably already created a new pathway that is not yet visible to the human geographical imagination. We should continue to try to manage all polioviruses in relation to the various bodies, ecologies, and geopolitical realities through which those viruses circulate to mitigate human suff ering. But we must also be aware that polioviruses are already locating openings for survival, and creating new viral geographies. The endgame is not eradication, but mitigation and adaptation.