Saturday, November 12, 2016

Hopes and Fears

BANGLADESH, 16 OCTOBER 1975

As man advances in civilisation, and small tribes are united into larger communities, the simplest reason would tell each individual that he ought to extend his social instincts and sympathies to all the members of the same nation, though personally unknown to him. This point being once reached, there is only an artificial barrier to prevent his sympathies extending to the men of all nations and races.
Charles Darwin, 1871. The Descent of Man

The hopes and fears of all the years are met in thee tonight.
Phillip Brooks, 1868, O Little Town of Bethlehem,

The world was sick, and the ills from which it was suffering were mainly due to the perversion of man, his inability to live at peace with himself. The microbe was no longer the main enemy; science was sufficiently advanced to be able to cope with it admirably, if it were not for such barriers as superstition, ignorance, religious intolerance, misery and poverty.
Brock Chisholm, first Director-General of the World Health Organization, 1948

Like many nineteenth century Christian hymns, the Christmas carol O Little Town of Bethlehem is a little overblown and, even at the time of its creation, was factually dubious as the quest for the historical Jesus had already recast the contradictory accounts of his birth as mere myths. And yet one sentence from the hymn rang true on 16th October 1975: not applied to a Judean village, but to an island settlement half a world away. The hopes and fears of all the years were met that day in the Bangladeshi village of Kuralia on Bhola Island, situated at the mouth of the Meghna River in the mighty Ganges Delta.
The last case of variola major, the life-threatening form of smallpox. The culmination of a global eradication campaign stretching back nearly two centuries to Jenner. In England’s green and pleasant land, where Jenner kick-started the process of eradication, every town and village sports a memorial to the dead of two world wars. Yet you look in vain for a list of the pox-dead. Responsible for a third to a quarter of a billion deaths in the twentieth century alone—more than double the combined death toll of all that century’s the wars—smallpox outdid Stalin, Hitler or Mao Zedong as a mass murderer during humanity’s bloodiest century. To memorialise the twentieth-century pox-dead would require five thousand Menin Gates or a Vietnam-style Memorial Wall 250 miles long.


Around the same time that American priest Phillip Brooks was writing O Little Town of Bethlehem, English naturalist, Charles Darwin was writing The Descent of Man, in which he predicted an expanding circle of sympathy “extending to the men of all nations and races”. From a global perspective, the century that connected the 1870s to the 1970s provided scant evidence for Darwin’s “expanding circle of sympathy”, with an unending litany of manmade megadeaths: imperialist wars across the globe from China to the southern tip of Africa, “manifest destiny” as an excuse for the US to massacre Native Americans, the decimation of the Congo Free State, two World Wars and the Holocaust. The second half of the twentieth century saw a world splintered into two by the Cold War. Stalin’s gulag and Mao’s Great Leap Forward. The Korean War. By October 1975, the Vietnam War had come to an end a few months earlier with the fall of Saigon; Cambodia’s killing fields were about to swallow two million dead.
And yet the candle of civilisation was never extinguished, nor the dream of eradication. At spes infracta. And yet hope unbroken, as the motto goes. Darwin’s expanding circle of sympathy was keeping pace with man’s inhumanity to man.

BY THE END OF WORLD WAR II, smallpox was no longer circulating among the populations of Europe and North America. Nonetheless, there were still frequent importations from the rest of the world, often triggering troublesome outbreaks. Vaccination in the rest of the world was hampered by the instability of the smallpox vaccine, which would start to lose potency after just a few days at ambient temperature. Widespread deployment of the vaccine meant the establishment and maintenance of a cumbersome “cold chain” to protect the vaccine.
American researchers had developed a method of freeze-drying the vaccine. However, their method added phenol to the vaccine to prevent bacterial contamination and, unhelpfully, the phenol rendered the vaccinia virus less active. In the late 1940s, a young English virologist, Leslie Collier (1921–2011), working at the Lister Institute of Preventive Medicine in Elstree, about thirteen miles north of London, came up with a solution. Collier added a crucial component to the process: peptone, a soluble protein extract that protected the virus during freeze-drying. Collier’s method delivered a heat-stable vaccine in powdered form that health workers could carry for weeks or months in their bags with no loss of potency.
In 1950, under the guidance of visionary American epidemiologist Frederick Soper, the Pan-American Health Organization launched a campaign to eradicate smallpox from the Western Hemisphere. Progress was slow, but, by 1958, the disease had been eliminated from all but four countries in the Americas: Argentina, Brazil, Colombia, Ecuador.
In many ways, smallpox was a sitting duck. We had a heat-stable vaccine that worked. Smallpox was an exclusively human disease, with no known substantial or durable animal or environmental reservoir. It was relatively easy to diagnose on clinical examination and distinctive enough even for the non-expert to spot. And yet, in the late 1950s, two million people were still dying from smallpox every year!

If the world were run on realism, it would be grey and miserable place. Repeatedly over the last two hundred years, idealists have set new targets, which realists would judge unrealistic; not feasible; not even desirable, if one thinks through all the potential consequences. In France, the nineteenth century opened to the cry of “libert√©, egalit√©, fraternit√©”, while in Britain it saw the abolition of slavery and the emancipation of Catholics. During the late nineteenth and early twentieth century, a wave of political idealism took hold in the Anglo-Saxon world, with Gladstone and later Woodrow Wilson articulating and enacting foreign policies that reflected the internal ideals of their societies—in effect, aiming to remake the whole world anew and in the image of their own societies.
Such idealism was soon to be subsumed into ideology in the brutal middle decades of the twentieth century. But even at the height of the cold war, both the West and the Soviets subscribed, however imperfectly, to the common ideals of feeding the hungry, educating the ignorant and healing the sick.  
After the Second World War, this sense of common humanity led to the formation of the United Nations and its subsidiary agencies, including the World Bank, the International Monetary Fund, the Food and Agriculture Organisation, the United Nations Educational, Scientific and Cultural Organization (UNESCO) and crucially the World Health Organisation or WHO.

The WHO was LAUNCHED in 1948 under the stewardship of Dr Brock Chisholm, a maverick Canadian psychiatrist, whose conviction politics had earned him the title of “Canada's most famously articulate angry man”. It was Chisholm’s idealism and high hopes for the new organisation that led to it being named the World Health Organisation, with a global rather being merely international mission. In harmony with its grand ambitions, the new organisation took up home in le Palais des Nations in Geneva, Switzerland; this former home of the League of Nations, overlooking Lake Geneva and with a clear view of the French Alps, peacocks roaming freely in the surrounding park, ranks as the second-largest building complex in Europe, second only to Versaille.
The new organisation’s policies and goals, in pursuit of Chisholm’s heady ideal of “World Health”, were set by the World Health Assembly (WHA), which acted as the WHO’s legislative and supreme body and met yearly in Geneva. Repeatedly during its first decade, in 1950, 1953, 1954 and 1955, the Wold Health Assembly discussed the global problem of smallpox. Chisholm himself proposed a smallpox eradication programme to the Sixth World Health Assembly in 1953, but his plans came to nought—after two years, after much debate, the Eighth World Health Assembly rejected the concept as unrealistic.
To mark the organization’s tenth anniversary, delegates from the over eighty member states of the WHO convened at the Eleventh World Health Assembly, for a three-week meeting that took place between May 28 and June 13, 1958. There was a crucial break with tradition—instead of the usual Switzerland, this time the United States of America played host to the meeting, thanks to the efforts of Hubert Humphrey, Senator for Minnesota and a long-time internationalist who wanted to highlight American support for the organization. The Eleventh WHA opened in Minneapolis, under the chairmanship of Dr Leroy E. Burney, Surgeon General of the US Public Health Service, with a two-day special session commemorating the Organization's tenth anniversary.
There was another change that year. Since just after its inception, the Soviet Bloc had boycotted the WHO, protesting that it did not allocate sufficient resources to Eastern Europe. During its first decade, the WHO stubbornly ignored Soviet absenteeism, arguing that its constitution contained no provision for withdrawal and so all these countries still counted as members. This left the door open for subsequent Soviet engagement with the organization. In line with Soviet premier Nikita Khrushchev’s new policy of “peaceful coexistence” with the West, that year, for the first time, the Soviet Union sent a delegation to the WHA: a delegation headed by the Soviet Union’s Deputy Health Minister, Victor Zhdanov.
And so, it was here in Minneapolis in the American Midwest, thanks to the hospitality of an American idealist and the intervention of a clear-sighted Russian clinician, the WHO finally grasped the thorny rose of idealism with the firm and decisive hand of realism and set in motion a train of events that still counts as one of humanity’s greatest achievements.

Victor Mikhailovich Zhdanov was born in 1914 into the family of a rural doctor in the village of Shtepin, tucked away in the southeastern corner of the Ukraine in what is now the Donetsk region, close to the Aral Sea. As a hint of the greatness that was to come, while at school, the young Zhdanov wrote a physics textbook for his classmates. On leaving school, to fund his medical studies and to gain preferential treatment during the admissions process, he worked on a farm for several months, where his natural leadership skills soon led to him being elected foreman.
Zhdanov then moved a few hundred miles north to the Ukraine’s second city, Kharkov to start his medical training. While studying at the Kharkov Medical Institute, the lively medical student enjoyed a full programme of extra-curricular activities, including playing the piano as an accompaniment to silent movies and writing and directing an opera. He graduated from the Institute at the age of twenty-two, then spent ten years in the “school of hard knocks”, working his way up the ranks as an army doctor in Novokuznetsk and Chita in Siberia, and then in Ashkhabad in Turkmenistan, eventually becoming a Major General. During this time, he learnt how to deal with bureaucrats and gained a mastery of epidemiology out in the field. Crucially, he was involved in efforts to eliminate malaria and dysentery, in the development and implementation of quarantine measures and in the containment of imported infections, all of which laid the foundations for his later thinking
In 1946, at the age of thirty-two, Zhdanov defended a doctoral thesis entitled Infectious hepatitis (Botkin's disease): Etiology and Epidemiology and throughout his life he maintained the critical mindset of a research scientist. That same year, following his release from the army, he became Chief of the Epidemiology Department in the Metchnikoff Institute of Epidemiology and Microbiology in Kharkov. Within two years, he had become Director of the Institute.  Within four years, he was a professor and had been elected a corresponding member of the USSR’s Academy of Medical Sciences.
A good listener, hard-working, well-organised, sharp-witted, encyclopaedically knowledgeable, with an extraordinary thirst for life, Viktor Zhdanov had all the makings of an inspiring and effective leader. In 1951, he became Chief of the Department of Sanitary and Epidemiological Services, with responsibility for communicable disease control across the whole of the Soviet Union. Fuelled by Soviet idealism and Soviet successes in controlling smallpox and Guinea-worm, combined with a keen intellect and warm humanitarianism, he was increasingly drawn to the idea of disease eradication. In 1952, with fellow microbiologist Vladimir Dmitrievich Timakov, Zhdanov published a report outlining the prospects for eliminating selected infectious diseases, stressing that increased investment in the short term was sure to deliver decisive savings in the long term.
In 1955 Zhdanov became Deputy Minister of Health and Chief Medical Officer, serving under the Soviet Minister of Health, the neurologist Dr. Maria Kovrigina. In this role, he formulated a strategy for tackling health problems that combined scientific analysis, wide-ranging discussion and decisive action. Such an approach was to serve him—and the world—well, when he turned his mind to the eradication of smallpox not just from the Soviet Union, but from the entire globe.
And so in 1958, as spring was turning into summer in Minneapolis, Zhdanov presented a report to the eleventh WHA. According to the official history of smallpox eradication, the report was rather long and couched in overly formal language, but few other declarations have had such power to change the course of history. As a sophisticated orator, Zhdanov tailored his rhetoric to the local audience, opening his address with an uplifting exhortation from US founding father Thomas Jefferson, in his 1806 letter to Edward Jenner: “future nations will know by history only that the loathsome small-pox has existed.”
Zhdanov’s report rammed home the point that no nation was free of the risk of smallpox until all were free of the disease, highlighting the recurrent costs of vaccination and revaccination across the globe and stressing that there were good grounds for believing that eradication was theoretically and practically possible. Zhdanov recommended that a system used in England to manage the disease, the so-called Leicester system, be adopted widely: this system encompassed prompt identification and isolation of new cases together with quarantine and surveillance of contacts. His report concluded with a bold claim: “As regards its complete eradication throughout the world, we think that this can be achieved within the next ten years.”

Zhdanov did not single-handedly and instantaneously win over his audience in 1958. The delegates did, however, ask the Director-General of the WHO to give fuller consideration to the prospect of smallpox eradication. The Soviet Union, and its ally Cuba, quickly followed up Zhadnov’s suggestion with practical help by supplying the WHO with 25 million and two million vials of vaccine, respectively. At the subsequent World Health Assembly in 1959, agreement was finally reached to launch a global eradication campaign for smallpox.

Although the speech that launched the eradication campaign had been given in America, the USA was initially slow to follow the Soviet Union’s lead. However, in 1964, which as International Cooperation Year marked the twentieth anniversary of the United Nations, President Lyndon B. Johnson pledged his country’s commitment to this bold effort. In a nice symmetry with the Soviet Union’s Zhdanov, one American, Donald “D.A.” Henderson, was subsequently propelled into a leadership role in the eradication campaign. Henderson was an epidemiologist working in the Epidemic Intelligence Service of the US. Centers for Disease Control (CDC) and he had become obsessed with smallpox. Henderson’s work in expanding an US-led effort to eradicate measles from West Africa to embrace smallpox control caught the attention of the then WHO Secretary-General, Chisholm’s successor, Marcelino Candau. In 1966, the WHA agreed on a ten-year intensified eradication campaign and Henderson was tipped into the role of Director of the WHO Smallpox Eradication Office. From his cramped headquarters in Geneva, Henderson led the campaign during its most active phase, channelling efforts through WHO Regional Offices to over 150,000 field workers.

This is not the place to document the details of how smallpox was squeezed out of every corner of the globe: the story of this campaign has been told many times before, most notably in the mammoth WHO publication, often dubbed “the Big Red Book”, Smallpox and its Eradication and in Henderson’s own account of the campaign, Smallpox—Death of a Disease. Suffice it to say that the campaign overcame numerous hurdles, both physical (mountains, rivers, floods) and social (ignorance, political wrangling, vested interests, national pride, fraudulent under-reporting of cases, famine, war, displacement of people) and every conceivable form of transport was used to deliver vaccine to its targets: jeeps, motorcycles, pushbikes, mules, boats, even elephants! One by one the regional goliaths of endemic smallpox fell to the slingshot of freeze-dried vaccine delivered by bifurcated needle—Brazil and Indonesia, West Africa, the Indian Subcontinent. An incursion by smallpox into Yugoslavia in 1970 was soon seen off. By 1975, smallpox was confined to two localities and only in one of them did the serious form, variola major, still inhabit human flesh and blood.