To begin with, smallpox eradication owed a great deal to biology. Compared to other diseases, smallpox was simply easier to eradicate. It was easy to see and diagnose (no asymptomatic infections) and did not re-infect people once gone. The disease’s painful symptoms prevented movement, slowing transmission. Moreover, the vaccine was easy to administer and extremely effective. There was no virus reservoir among animals re-injecting the disease into human society again and again.
Diseases like malaria and polio had far more natural advantages, and have proven much harder to eradicate globally.
‘Without the particular characteristics of smallpox and the smallpox vaccine,’ historian Randall Packard has observed, ‘the disease would have been much more difficult to conquer, and the campaign would, in all likelihood, have failed. As it was, it only succeeded by the thinnest of margins.’
One particular challenge was how to handle Nepalis who resisted vaccination. In the eastern Tarai, many people, particularly indigenous groups, held what a WHO report described as ‘religious objections to vaccination’.
WHO said this area became ‘the scene of many problems of containment’. In Kathmandu, some Newar groups used to ‘strongly object’ to vaccination. In Kailali, some Tharus ‘resisted vaccination for religious reasons’.
Historian Susan Heydon notes that program workers often unjustifiably dismissed the concerns of Nepalis who resisted vaccination. Those who hesitated, she notes, were blamed as superstitious, derided as ‘backward and uneducated’.
Instead, she faults the WHO program itself for not doing enough to educate the general population about the benefits of vaccination. She also notes that the program often administered vaccinations during hours next to impossible for ordinary working people.
Eradication program workers also occasionally used unnecessary coercion. Coerced vaccinations were not common worldwide or in South Asia. But as historian Packard notes, there was a ‘tendency for aid workers to view themselves as somehow empowered to do whatever it takes to fulfill their mission, and to disregard local customs and laws’.
In India and Bangladesh, historian Paul Greenough discovered that ‘heavy-handed methods were sometimes relied upon’. On one occasion in Bihar in 1975, for example, health officials accompanied by police arrived at a tribal person’s house by jeep at midnight, broke down the door, held down family members, and forcibly vaccinated them. Mandatory vaccinations and re-vaccinations as part of broad containment efforts sometimes sparked ‘chaos’ in villages.
‘Encounters with government vaccinators,’ Greenough observes, were ‘never about immunisation alone.’ Religious, caste, and gender dynamics shaped interactions, as did ill will from previous health campaigns.
One American health worker in India later recalled how a sense of unbridled self-righteousness led him to mistreat people. ‘One of the rules was that everybody gets vaccinated. I was awful in my conviction of purity of purpose — in breaking down doors and vaccinating crying women, etc.’ To a large degree, the ends seemed to justify the means.
Official reports, Greenough writes, often dismissed resistance and underreported coercion. He wishes there had been much more training for healthworkers and broader,more careful education for the public.