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The improbable victory over smallpox holds lessons for health threats in 2024
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Smallpox was certified eradicated in 1980, but I first learned about the disease's twisty, storied history in 1996 while interning at the World Health Organization. I was a college student fascinated by the sheer magnitude of what it took to wipe a human disease from the earth for the first time.
Over the years, I've turned to that history over and over, looking for inspiration and direction on how to be more ambitious when confronting other public health threats of my day.
In the late 1990s, I had the opportunity to meet some of the health-care professionals and other eradication campaign workers who helped stop the disease. I came to see that the history of this remarkable achievement had been told through the eyes mostly of white men from the United States, what was then the Soviet Union, and other parts of Europe.
But I knew that there was more to tell, and I worried that the stories of legions of public health workers in South Asia could be lost forever. With its dense urban slums, sparse rural villages, complicated geopolitics, corrupt governance in some corners and punishing terrain, South Asia had been the hardest battlefield for smallpox eradicators to conquer. So I decided to capture some of that history. That work became a podcast, an eight-episode, limited-series audio documentary, called "Epidemic: Eradicating Smallpox."
My field reporting began in summer 2022, when I traveled to India and Bangladesh — the site of a grueling battle in the war on the disease. I tracked down aging smallpox workers, some now in their 80s and 90s, who had done the painstaking work of hunting down every last case of smallpox in the region and vaccinating everyone who'd been exposed. Many of the smallpox campaign veterans had fallen out of touch with one another. Their friendships had been forged at a time when long-distance calls were expensive and telegrams were still used for urgent messages.
How did they defeat smallpox? And what lessons does that victory hold for us today?
I also documented the stories of people who contracted smallpox and lived. What can we learn from them? The survivors I met are not unlike my father, who grew up in a rural village in southern India where his childhood was shaped by family finances that limited access to opportunity. The stories he shared with me about the big social and economic divides in India fueled my decision to choose a career in public health and to work for equity. As we emerge from the COVID pandemic, that connection is a big part of why I wanted to go back in time in search of answers to the challenges we face today.
Unwarranted Optimism
I sought out Indian and Bangladeshi public health workers, as well as the WHO epidemiologists — largely from the U.S. and Europe — who'd designed and orchestrated the eradication campaigns across South Asia. Those smallpox leaders of the 1960s and '70s showed moral imagination: While many doctors and scientists thought it would be impossible to stop a disease that had lasted for millennia, the eradication champions had a wider vision for how the world could see not just less smallpox, or fewer deaths, but elimination of the disease completely. They did not limit themselves to obvious or incremental improvements.
Dr. Bill Foege, a campaign leader in the 1970s, says by contrast today's policymakers can be reluctant to support programs that don't already have data to back them up. They typically want proof of sustainability before investing in novel programs, he says, but real-world sustainability often only becomes clear when new ideas are put into practice and at scale.
The smallpox eradication visionaries were different. "They had 'unwarranted optimism,'" Foege said. They had faith that they could make "something happen that could not have been foreseen."
In India, in particular, many leaders hoped their nation could compete with other superpowers on the world stage. That idealism, in part, stoked their belief that smallpox could be stopped.
During the smallpox program in South Asia, Dr. Mahendra Dutta was one the biggest risk-takers — willing to look beyond the pragmatic and politically palatable. He was a physician and public health leader who used his political savvy to help usher in a transformative smallpox vaccination strategy across India.
The eradication campaign had been grinding in India for over a decade. India had invested time and resources — and no small amount of publicity — into a mass vaccination approach. But the virus was still spreading out of control. Dutta's was one of the voices that proclaimed to India's policymakers that mass vaccination wasn't working, at a time when India's leaders were eager to project strength as a superpower and protective of the nation's image on the world stage.
Dutta told them it was past time for India to adopt a new, more targeted vaccine strategy called "search and containment." Teams of eradication workers visited communities across India to track down active cases of smallpox. Whenever they found a case, health workers would isolate the infected person then vaccinate anyone that individual might have come in contact with.
To smooth the way for the new strategy, Dutta called in favors and even threatened to resign from his job.
He died in 2020, but I spoke with his son Dr. Yogesh Parashar, who said Dutta straddled two worlds: the in-the-trenches realities of smallpox eradication and India's bureaucracy. "My father did all the dirty work. He got enemies also in the process, I'm sure he did, but that is what he did," Parashar said.
Coping with crises and respecting local culture
Smallpox workers understood the need to build trust through partnerships: The WHO's global smallpox eradication program paired its epidemiologists with Indian and Bangladeshi community health workers, who included laypeople with training and eager and idealistic medical students. Those local smallpox eradication workers were trusted messengers of the public health program. They leveraged the region's myriad cultures and traditions to pave the way for people to accept the smallpox campaign and overcome vaccine hesitation. While encouraging vaccine acceptance, some of the cultural practices they embraced included using folk songs to spread public health messages and honoring the way locals used the leaves of the neem tree to alert others to stay away from the home of someone infected with smallpox.
But smallpox eradication in South Asia unfolded against a backdrop of natural disaster, civil war, sectarian violence and famine — crises that created many pressing needs. By many, many measures, the program was a success. Indeed, smallpox was stopped. Still, in the all-consuming push to end the virus, public health writ large often failed to meet people's basic needs, such as housing or food.
The smallpox workers I interviewed say that they were sometimes confronted by locals who made it clear they had concerns that, even in the midst of a raging epidemic, felt more immediate and important than smallpox.
Eradication worker Shahidul Haq Khan, whom podcast listeners meet in Episode 4, heard that sentiment as he traveled from community to community in southern Bangladesh. People asked him: "There's no rice in people's stomachs, so what is a vaccine going to do?" he said.
But the eradication mission largely did not include meeting immediate needs, so often the health workers' hands were tied.
When a community's immediate concerns aren't addressed by public health, it can feel like disregard — and it's a mistake, one that hurts public health's reputation and future effectiveness. When public health representatives return to a community years or decades later, the memory of disregard can make it much harder to enlist the cooperation needed to respond to the next public health crises.
The toddler who contracted the last naturally occurring case
The eradication of smallpox was one of humankind's greatest triumphs, but many people — even the grandest example of that victory — did not share in the win. That realization hit me hard when I met Rahima Banu. As a toddler, she was the last person in the world known to have contracted a naturally occurring case of variola major smallpox. As a little girl, she and her family had — for a time — unprecedented access to care and attention from public health workers hustling to contain smallpox.
But that attention did not stabilize the family long-term or lift them from poverty.
Banu became a symbol of the eradication effort, but she did not share in the prestige or rewards that came after. Nearly 50 years later, Banu, her husband, their three daughters, and a son share a one-room bamboo-and-corrugated-metal home with a mud floor. Their finances are precarious. The family cannot afford good health care or to send their daughter to college. In recent years when she's had health problems or troubles with her eyesight, there have been no public health workers bustling around, ready to help.
"I cannot thread a needle because I cannot see clearly. I cannot examine the lice on my son's head. I cannot read the Quran well because of my vision," Banu said in Bengali, speaking through a translator. "No one wants to know how I am living my life with my husband and children, whether I am in a good condition or not, whether I am settled in my life or not."
Mistakes of the past are repeated today
I believe some of our public health efforts today are repeating mistakes of the smallpox eradication campaign, failing to meet people's basic needs and missing opportunities to use the current crisis or epidemic to make sustained improvements in overall health.
The 2022 fight against mpox is one example. The highly contagious virus spiked around the world and spread quickly, predominantly among men who have sex with men. In New York City, for example, in part, because some Black and Hispanic people had a historical mistrust for city officials, those groups ended up with lower rates of mpox vaccination. And that failure to vaccinate became a missed opportunity to provide education, access to HIV testing and prevention, or other health care.
And so has it gone with the COVID pandemic, too. Health-care providers, the clergy and leaders from communities of color were enlisted to promote immunization. These trusted messengers were successful in narrowing race-related disparities in vaccination coverage, not only protecting their own but also shielding hospitals from crushing patient loads. Many weren't paid to do this work. They stepped up despite having good reason to mistrust the health care system. In some ways, government officials upheld their end of the social contract, providing social and economic support to help these communities weather the pandemic.
But now we're back to business as usual, with financial, housing, food, health care, and caregiving insecurity all on the rise in the U.S. What trust was built with these communities is again eroding. Insecurity, a form of worry over unmet basic needs, robs us of our ability to imagine big and better. Our insecurity about immediate needs like health care and caregiving is corroding trust in government, other institutions, and one another, leaving us less prepared for the next public health crisis.
Dr. Céline Gounder, a physician and epidemiologist, is a senior fellow at KFF and the editor-at-large for public health at KFF Health News. She hosts the limited-series podcast "Epidemic: Eradicating Smallpox."
KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling and journalism.
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