India’s War on Smallpox: Lessons for the Covid19 Pandemic

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    Forty-four years ago, in the last week of April 1977, the World Health Organisation (WHO) declared India free of one of its deadliest scourges – smallpox. After losing hundreds of thousands of lives due to recurring outbreaks over several centuries, the visitations of Goddess Shitala Mata, the Goddess of Smallpox, had finally ended.

    At one point, India had 60 per cent of the world’s smallpox cases, so the triumph was especially impressive. The eradication of the disease had been achieved due to sheer grit and determination, an innovative method to contain the disease, a mind-boggling logistical exercise, and the commitment of the Indian government to wiping out the epidemic from the country.

    Astonishingly, the final assault in India took just two years for the country to be declared smallpox-free.

    There are many parallels between the smallpox epidemics that devastated different countries in the 20th century and the Covid19 pandemic that is taking a horrific toll across the world, especially India, today. More importantly, there are many invaluable lessons that we can learn to halt the march of this highly contagious disease.

    When the WHO was set up in 1948, smallpox was infecting around 50 million people every year. Moreover, it was beyond the scope of any single nation to control it. The disease was deadly, with a fatality rate of 30 per cent. It was also incurable.

    Mass vaccination against smallpox began only in the late 1950s and, until then, the only known way to keep the disease at bay and curb its spread was a technique called variolation. Used by people in many countries, it was a method by which a healthy individual was infected with the smallpox virus taken from the scabs or pus of an infected person.

    The smallpox vaccine – the first vaccine to be developed against a contagious disease – was developed in the 18th century by Edward Jenner.

    But, it was not until the late 1950s that mass vaccination could take place.

    Until then, the international community had been helpless in the face of the disease and the WHO was not convinced that it could be eradicated. They also did not know why mass vaccination worked in some places and not in others.

    It was Soviet epidemiologist and Deputy Health Minister in the Soviet Union, Dr Viktor Zhdanov, who convinced the WHO that a worldwide eradication programme could succeed. He had experienced great success in containing the disease in the Soviet Union and was a respected voice in the global campaign against smallpox.

    1962 and 1967: First And Second Mass Campaigns

    Buoyed by Dr Zhdanov’s optimism, the Indian government launched the National Smallpox Eradication Programme (NSEP) in 1962. The biggest challenge was reaching out to people in remote areas as the vaccine had to be refrigerated, and transporting it was extremely difficult.

    Dr Zhdanov made a bold suggestion. He advocated freeze-drying the vaccine, an almost magical solution. Freeze-drying was a technique that had been widely used to transport blood plasma during World War II and using it on a vaccine would be a first. Freeze-dried vaccines could be transported anywhere, at ambient temperatures, then rehydrated and reconstituted, and administered on the spot immediately before vaccination.

    A plant to manufacture freeze-dried vaccines was set up in Madras, at the King’s Institute of Preventive Medicine & Research. Later, three more such production centres were set up in different parts of India.

    But even after millions of primary vaccinations and re-vaccinations had been administered, the disease remained endemic in India, Pakistan, Afghanistan, Nepal and most countries in sub-Saharan Africa.

    In 1957, the WHO launched a new Intensified Smallpox Eradication Programme in India. At around the same time, an American doctor working with missionaries on the national smallpox vaccination programme in Nigeria had made a breakthrough. He came up with a technique that would revolutionise the way in which the disease was contained. His name was Dr William H Foege and he would go on to play a key role in India as well.

    Since vaccines were in short supply, Dr Foege reckoned that the best he could do was to ‘ring-fence’ pockets riddled with the disease, to stop the infection from spreading outside these areas. Ring-fencing is a technique used to control forest fires, in which trees are cut in a circular band around a fire to prevent the blaze from spreading. For Dr Foege, ring-fencing smallpox hotspots meant vaccinating the people around these spots, thus forming a ‘ring of immunity’ around the disease, so that it couldn’t spread.

    Did it work? Through a combination of careful monitoring and surveillance, targeted vaccination and containment or ring-fencing, the outbreak in the region where Dr Foege was working was brought under control in just five months.

    While Dr Foege had achieved success with the surveillance-containment method in Nigeria, this technique was confirmed in India by Dr A Ramachandra Rao, a doctor at the civic-run Communicable Diseases Hospital in Madras who used it to stop smallpox from spreading across Madras State (now Tamil Nadu).

    1973: The Final Assault

    These results from the ground had an impact on the thinking within the WHO, which in 1970 came to believe that the variola major virus, which caused smallpox, was not as resilient as they had assumed and that its transmission could be interrupted more easily than believed earlier.

    In September 1970, the Indian government signed an agreement with the WHO for another eradication programme and, in June 1973, the WHO initiated the surveillance-containment method across India. It was through this technique that the epidemic was finally stamped out – and it took only two years.

    To implement the plan, a WHO team arrived in India in 1971. Headed by French-Swiss virologist Dr Nicole Grasset, it included Dr Foege and Czech epidemiologist Zdeno Jezek. The most colourful member of the team, however, was its fourth – Dr Larry Brilliant, who joined the WHO in Delhi.

    After completing his medical studies in the United States in 1969, Dr Brilliant had travelled in a bus along with a group of hippies to India, lured by its spiritual fame. Dressed in a kurta and pyjama, Brilliant ended up in India at the hill hermitage of ‘Guru Neem Karoli Baba’ at Kainchi, not far from Nainital in Uttarakhand (then Uttar Pradesh).

    Fate, however, had a much higher purpose in store for him. Upon learning that he was a doctor, his guru, or spiritual leader, told him he should join the programme to conquer smallpox in India. In 1972, Dr Brilliant joined the WHO in its Delhi office as a secretary as there were no funds to accommodate a doctor in the team. In any case, he was a very young doctor with scanty experience in dealing with smallpox.

    He became a part of the main team when a Soviet doctor dropped out and he worked his way through the programme. He continued to work in India as a medical officer with the United Nations for more than a decade, and later joined the war against polio in India!

    Dr Brilliant was as audacious as he was spiritual, and he strode into the home of Russi Mody, head of Tata Iron and Steel Company, to help tackle the problem in Jamshedpur. This was a hotspot from where smallpox was being transmitted to other parts of the country. He even met industrialist and Tata head of the group J R D Tata and persuaded him to donate generously to the eradication programme.

    In June 1973, the WHO team quite literally launched a manhunt for the smallpox virus across India. For six days a week, every month, and for 20 months beginning 1973, when the intensified programme was launched in India, 3 million health workers and doctors visited 100 million households in more than 5.75 lakh villages and 2,641 cities and towns, in a house-to-house manhunt for the smallpox virus. A total of 2 billion house calls were made. It was a gigantic exercise by any standards.

    The search-and-surveillance by the team of health workers was supplemented by the announcement of a reward of a hundred rupees (a large enough sum in those days!) for every case of smallpox reported, to encourage people to come forward. Many were concealing the disease for fear of the stigma and social isolation associated with it.

    People would visit temples dedicated to Goddess Shitala Mata, to propitiate her and pray for a cure. So team members followed people visiting these temples back to their homes, and many cases were discovered in this way.

    Overall, the results were dramatic. There was a sudden spike in the number of cases reported but the smallpox team was certain that this was the result of accurate reporting, not an increase in the incidence of the disease. And accurate reporting was one of the pillars of the eradication campaign.

    They were confident that it signalled the beginning of the end of smallpox in India. And they turned out to be right. There had been massive under-reporting in the past. In 1967, for instance, it was discovered later, that only 1 per cent of cases had been reported.

    This war on smallpox required the collection and analysis of huge quantities of data and it was estimated that each country-wide survey in India had consumed 8 tons of paper. In those pre-computer days, this enormous amount of data was submitted, processed and analysed at lightning speed.

    Crucial Support From Government

    Although the campaign was being implemented strictly by experts, the Indian government threw its weight behind it. This is a message written by then Prime Minister Indira Gandhi to market the programme, in October 1973, an indication of how seriously the government was taking the war on smallpox:

    “Smallpox has been wiped out in most countries. India is unfortunately one of the small number where cases of smallpox still occur. Modern medicine can enable us to eradicate this disease. I am glad to learn that an intensive three-month anti-smallpox campaign has been launched, particularly in the states of Uttar Pradesh, Madhya Pradesh, Bihar and West Bengal.

    “This movement requires the fullest cooperation of all citizens. Parents especially must ensure that their children and indeed all young children in the neighbourhood are vaccinated against smallpox.”

    The rest of the work was left to the head of the National Institute of Communicable Diseases (later the National Centre for Disease Control) Dr Muni Indra Dev Sharma, who was Director during that time, and Dr Mahendra Dutta, who was heading the Health Ministry’s smallpox programme.

    Dr Donald A Henderson, head of the WHO’s smallpox eradication unit, later recalled how the WHO team had sat down with officials of the Indian government to work out a plan to visit every house in every village in India.

    On 17th May 1975, the last case of smallpox was reported in India, that of a 30-year-old woman in Bihar.

    Two years later – after a national audit followed by an audit by the WHO – India was declared free of smallpox.

    The journey had been long and tortuous, painstaking and at times and very frustrating. But in the end, it was described as the greatest-ever public health success, globally.

    After India, the only countries with endemic smallpox were Bangladesh, Ethiopia and Somalia. Finally, in December 1979, two and a half years after India, the world was declared smallpox-free. It was an achievement in which India had played an important role, as it was where the surveillance-containment method had first been tested, with phenomenal success, on such a mass scale.

    Despite the toll and suffering India had to endure, the country had contributed in no small measure to saving hundreds of thousands of lives around the world.

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    Kalyan Chatterjee is a Delhi NCR-based freelance journalist. He worked as a full-time journalist in UNI and Deccan Herald. For 18 years he taught mass communication. He is the author of a book Media and Nation Building in Twentieth Century India: Life and Times of Ramananda Chatterjee.

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