August 4, 2016

by Farren Yero

Throughout the last two weeks in the archive, the records I’ve encountered have challenged my understanding of what Cold War international health looked like at the level of administration. As I mentioned in my last post, the campaign has historically been told through a narrative that celebrates the straightforward success of the World Health Organization (WHO). The documents, however, present a very different story, one that is perhaps best exemplified in the reward poster below.

Courtesy of the World Health Organization

Courtesy of the World Health Organization

Designed by Rene Gauch, the poster offers a reward of $1000 US dollars to “the first person reporting an active smallpox case resulting from human to human transmission.” Rather than evoke the ethos of world peace, as the WHO frequently did in championing this cause, this poster plays on a different set of emotions to prompt public cooperation. It suggests that despite the rhetoric and bravado expressed in their official reports, smallpox was not so readily eradicated. Reminiscent of the images found in dystopic horror films, the haunting mask, composed of what we imagine to be the pustules of a smallpox victim, was intended to provoke the viewer into informing on his or her neighbors. As other scholars of the global campaign have noted, strategic surveillance turned out to be key to the success of their mission. This strategy was mobilized in the last decade of the global program in an effort to eradicate the vestiges of the virus. When cases erupted in far-flung villages, health workers could rely on this infrastructure of information to quickly contain the spread of the virus through targeted vaccinations.

As these surveillance strategies were being employed, national vaccination campaigns were drawing to an end. As fewer and fewer cases of smallpox were reported, international health administrators began to take seriously the notion of eradication and how it could be officially certified. These concerns ultimately raised a set of questions about what eradication really meant, and what kind of role “certification” would play in defining it.

For Dr. Fred Soper, the former director of the Pan American Health Organization, and leading voice on disease eradication, this was a complicated issue. In 1958, when the World Health Organization finally approved the smallpox eradication program, Soper prepared a speech, remarking that, “perhaps the greatest contribution of the PAHO since its reorganization in 1947 has been the development of the concept of eradication in the prevention of communicable disease” (NLM, Fred Lowe Soper Papers, Box 19, Folder 9).

His own ideas about the concept changed over time, so that by 1965, his priorities seemed to have shifted from outright elimination of the offending virus to the pursuit of “zero,” a reference to the ideal number of reported cases. In a letter to Dr. James Watt, of the U.S. Public Health Service, Soper wrote that “the certification of smallpox eradication [should] be taken up directly with the Director General of the World Health Organization,” following the guidelines first set out by the PAHO for certifying the eradication of the Aedes aegypti mosquito [the same species to carry yellow fever and the zika virus.]

He laid out a series of steps that they had used in this endeavor:

  1. A) The setting of PAHO standards for eradication by the technical staff of PAHO
  2. B) Field investigation by the technical staff of PAHO to determine compliance with these standards
  3. C) Certification by resolution of the Conference or Directing Council of PAHO

Defining a strategy that the WHO Expert Committee on Smallpox Eradication would adopt in 1972, Soper suggested to Watt that “such a proposal should serve to open countries for investigation by the PAHO workers any time the number of cases occurring approaches or reaches the zero level” (NLM, Fred Lowe Soper Papers, Box 19, Folder 2, Soper to Watt, July 7, 1965).

These strategies would be first employed in Brazil, where the eradication of smallpox was deemed imminent. Data was to be collected on the ground as part of a WHO commission visit, from which the status of smallpox would be assessed two years later. In the field, the certification process required almost as much persistence and coercion as the vaccination campaign itself. The investigations could seem intrusive, with campaign staff, in addition to conducting twice-yearly surveys, measuring facial pockmark scars for evidence of past outbreaks, probing arms for proof of vaccination, and administering vaccine to those who potentially lacked immunity. This data was collected as part of their surveillance

Surveillance Team Member Questions a Family about a Potential Smallpox Case, Brazil. Courtesy of the World Health Organization

Surveillance Team Member Questions a Family about a Potential Smallpox Case, Brazil. Courtesy of the World Health Organization

strategies and recorded in what the WHO referred to as “rumor registries.”

When I began looking into Latin America’s role in the WHO smallpox eradication program, my central focus was the campaign in Mexico. I had assumed that because vaccination continued to be mandated years after smallpox was essentially eradicated in that country it was likely that SEP field workers were sent there on the ground to investigate its status. This possibility intrigued me, because at the same time that the WHO began to launch its intensive eradication program, thousands upon thousands of political dissidents were murdered and disappeared throughout Latin America as part of what historians refer to as the Dirty Wars. It seemed incredible to me that in all of the histories of the global eradication program, this glaring detail was somehow missed.

As it turns out, this was not the case for Mexico. For countries that appeared to have rid themselves of smallpox early on, including all of North America, the WHO simply required an official statement from each national health authority declaring its eradication status. So although there were no reported cases of smallpox in Mexico after 1951, it took two decades and a reconceptualization of the value of “certification,” for the country’s claim to be smallpox-free to be recognized by global health authorities. For those who have followed the news about the zika virus over the past year, this conflict over certification will feel familiar. Numerous cases were reported and reported on by journalists in Brazil, but it was only after the WHO and the CDC officially declared it an epidemic that it was recognized as a legitimate public health threat.

So while SEP commissions do not appear to have been sent to Central America, they were deployed in almost all of South America, most notably in Brazil, where the certification schema, first designed by the Pan American Health Organization, was initially launched. What is all the more fascinating about this certification process is that even before global eradication was officially certified, the WHO had begun to write Smallpox and its Eradication, its 1,460 page self-published official history of the SEP, which was not actually published until 1988. In addition to surveillance Certification of Smallpox Eradicationand rumor registries, the WHO employed narrative as yet another tool in their disease eradication program.

It is worth noting that despite its certification, formalized in the document seen here, smallpox is not, in its truest sense of the word, eradicated. In the fabulous book, Pox Americana, Elizabeth Fenn recalls how the politics of the Cold War continued to shape the way international health organizations interacted with the smallpox virus, ultimately allowing it to persist, despite the decades of resources extended to bring about its eradication. The WHO had intended that only two repositories of the virus remain: one in the CDC in Atlanta, GA and the other in Russia. It was planned that on June 30, 1999, these two samples were to be simultaneously destroyed in an act of unprecedented international cooperation. It didn’t happen, of course. The US announced two months before the scheduled demise that it would retain its stores of the virus. Fearing that unknown samples of the virus were still at large, smallpox became a potential agent of biological terror, and as such, the US would not rid itself of what it believed to be a potential weapon.

I draw attention to these discrepancies to ask what it means that an international health organization, invested in political cooperation, actively crafted an official narrative of health and prosperity, one might even say, of order and progress, while it simultaneously deployed health workers throughout Brazil, during the darkest years of the dictatorship, in order to meet the standards of an official certification. According to the guides and manuals produced for the health teams, investigators were tasked with seeking out unreported cases, leaving no stone unturned. It is unlikely that in their investigations, which required, as scholars have frequently reminded us, high levels of community engagement, that they would have somehow been unaware of the human rights violations taking place throughout the country.

And so, we are left with a question: to what extent can we (and possibly, should we) expect humanitarian projects to take action against human rights violations carried out in the very countries that they actively seek to promote human health.

In that same 1958 speech, celebrating the concept of disease eradication, Dr. Soper invoked a message of unity in the face of Cold War hostilities:

“In the broader field of international political relationships, world wide disease eradication is setting a pattern for international collaboration, the full impact of which cannot be foreseen. Possibly the greatest contribution of the international health agencies may not be in the field of health at all but in the politics of world cooperation by uniting mankind to meet the common challenge of communicable disease eradication.”

Soper reminded his colleagues repeatedly, because disease did not recognize national boundaries, global eradication would only be possible when countries worked together.

Today, we should ask ourselves, if global health is truly the mission, then what should international political cooperation really look like?

 

 

 

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