Crisis, charisma and triage: Extirpating the pox

Indian Economic and Social History Review

Volumn 40, Issue 4, 2003, Pages 425-457

  Naraindas, Harish ^a  

^a UNIVERSITY OF DELHI   (India)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 2442689225     PISSN: 00194646     EISSN: None     Source Type: Journal    
DOI: 10.1177/001946460304000403     Document Type: Review

References (85)

1. http://www.homelandsecurity.org/darkwinter/index.cfm
2. Edward H. Kaplan, David L. Craft and Lawrence M. Wein, 'Emergency Response to a Smallpox Attack: The Case for Mass Vaccination', Proceedings of the National Academy of the Sciences, Vol. 99, 2002, pp. 10935-40.
3. Harish Naraindas, 'Preparing for the Pox: A Theory of Smallpox in Bengal and Britain', Asian Journal of Social Sciences, Vol. 31, no. 2, 2003, pp. 304-39.
4. Harish Naraindas, 'Care, Welfare and Treason: The Advent of Vaccination in the 19th Century', Contributions to Indian Sociology (n.s.) 32(1), 1998, pp. 67-96.
5. Smallpox variolation as opposed to smallpox vaccination is the introduction of 'live' smallpox matter from the pustules or dried crusts of another smallpox patient. It was practised throughout the world and in India it was backed by professional variolators and a presiding deity. With the advent of vaccination, which was originally cowpox, variolation was portrayed both in India and Britain as a form of treason that needed to be outlawed on the ground that it set up epidemics and hence was a public threat. Cowpox, in opposition, was portrayed as something that could not be communicated from patient to patient. But Holwell's essay, as a normative text, allows us to recast this encounter. I have argued that the preference for variolation may have been due to the continuous failure of vaccination, making it a risky venture for individual patients. Variolation may have been preferred not only because it was tied to worship, but also because it was surer to 'take', and was a moment in a larger therapeutic structure. Hence, there was probably a pragmatic trade-off between vaccination, which was offered as safe by the state (but by its repeated failure leaving patients open to the ravages of smallpox), and variolation which, though notionally more risky, invariably 'took', and as a part of a larger therapeutics ensured individual care and safe passage to patients. For the full argument and the implications, see Naraindas, Care, Welfare and Treason.
6. The recounting of the incident at Pawapuri is primarily based on personal interviews with Dr Mahendra Dutta (Mahendra Dutta, 'Personal Interviews', August 1996, New Delhi). As Assistant Director-General of Health (Cholera) with the central government's Directorate General of Health Services (DGHS), he was appointed the central appraisal officer of Bihar during the last stage of the NSEP. During the course of interviews that spanned many hours and two sittings, he recounted his experiences with verve and enthusiasm. For that brief span of time he managed to transport me to a nether world that appeared capricious, bizarre and glorious in turns. It was an enactment that signalled the crossing of thresholds, of a liminal time and space; and his role as the chosen onethe man on the spot-who as the ultimate term of appeal bore the responsibility for the success or failure of the national-global eradication of smallpox, which toward the end seemed to rest on Bihar. I thank him for his time and warmth.
7. Brilliant, referring to the same incident, says that 'nearly 2,000 telegrams were sent to people suspected of having been in contact with an active case'. See Larry Brilliant, The Management of Smallpox in India, 1985, Ann Arbor; and Dutta said they were sent to '150 districts' (Dutta, 'Personal Interviews').
8. Brilliant, referring to the same incident, says that 'nearly 2,000 telegrams were sent to people suspected of having been in contact with an active case'. See Larry Brilliant, The Management of Smallpox in India, 1985, Ann Arbor; and Dutta said they were sent to '150 districts' (Dutta, 'Personal Interviews').
9. Dutta, 'Personal Interviews'.
10. It certainly seemed so to Donald Henderson, the then chief of the global eradication unit of the WHO. When he visited the site with Dr Dutta, he was amazed at the measures taken and admitted that he would have been unable to pull it off in the USA as it would have amounted to a violation of individual liberty. Dutta's response was one of puzzle and impatience. He wondered what was being violated when all he could see was a free-feed and a forced holiday. As he put it: 'The people were getting fed without working, what could be better than that' (Dutta, 'Personal Interviews'). Henderson's qualms (or was it admiration) did not seem to translate itself into anything.
11. I b i d.
12. In a 'General Order' published by the 'Governor-in-Council', dated '20 October 1821', it was resolved that the Bombay Presidency would have an exclusive vaccine establishment that would cover the whole Presidency (General Department 1821-23: 46/51, MSA).
13. Sir J. Bhore, Report of the Health Survey and Development Committee. 4 vols, Delhi, 1946.
14. I b i d.
15. R.N. Basu, N. Jezek and N.A. Ward, The Eradication of Smallpox in India, New Delhi, 1979, p. v.
16. Ibid., p. 23. The 1967 epidemic, like most others, seems to be symptomatic of an institutional breakdown and scarcity following a crisis, which in this case was the 'Indo-Pakistan war, devaluation of the rupee, general rise in prices and scarcity of many resources' (Brilliant, The Management of Smallpox, p. 14).
17. Ibid., p. 23. The 1967 epidemic, like most others, seems to be symptomatic of an institutional breakdown and scarcity following a crisis, which in this case was the 'Indo-Pakistan war, devaluation of the rupee, general rise in prices and scarcity of many resources' (Brilliant, The Management of Smallpox, p. 14).
18. We momentarily side-step a different sort of question, only to approach it later from elsewhere. And that is, instead of following suit, we could ask: why was mass vaccination successful in some areas and not others? Instead of resorting to the new strategy of 'surveillance and containment', why was mass vaccination not persisted with? This question acquires meaning because the new strategy was vertical: for a short period of time it threw all the state's resources into smallpox eradication to the virtual exclusion of everything else. The query from within the DGHS was: is this necessary? (Dutta. 'Personal Interviews'; R.N. Basu, Personal Interviews, New Delhi, 1996). Dr Basu said that this was a question repeatedly posed, and he and others who were converts to the new strategy were often at sea.
19. We momentarily side-step a different sort of question, only to approach it later from elsewhere. And that is, instead of following suit, we could ask: why was mass vaccination successful in some areas and not others? Instead of resorting to the new strategy of 'surveillance and containment', why was mass vaccination not persisted with? This question acquires meaning because the new strategy was vertical: for a short period of time it threw all the state's resources into smallpox eradication to the virtual exclusion of everything else. The query from within the DGHS was: is this necessary? (Dutta. 'Personal Interviews'; R.N. Basu, Personal Interviews, New Delhi, 1996). Dr Basu said that this was a question repeatedly posed, and he and others who were converts to the new strategy were often at sea.
20. Brilliant, The Management of Smallpox, p. 6.
21. Ibid., p. 124.
22. Since the incubation period of vaccination was shorter than the natural infection, if given promptly to contacts it either prevented smallpox, or modified it (Dutta, 'Personal Interviews'). But the opposite was equally true: vaccination would fail to be effective in all those cases where the incubation was well underway, resulting, as it has from its inception, in a loss of faith. Hence, apart from the rapid vaccination of contacts, their isolation and quarantine were stressed in the new strategy.
23. A good example of this is Sir Charles Rivaz, the 'incoming lieutenant 'governor' of the Punjab, who 'was to rely upon inoculation as the main means of containing plague and to immunize at least two-thirds of the population' (David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-century India, Delhi, 1993, p. 234).
24. William H. Foege, 'Strategy of Smallpox Eradication', Swasth Hind, Vol. XIX(4), 1975, pp. 119-22.
25. Ibid., p. 122.
26. I b i d.
27. Jerome Klein, 'Search and Destroy Missions to Beat Smallpox', Swasth Hind, Vol. XIX(4), 1975, pp. 123-24.
28. Based on personal interviews with Dr R.N. Basu (Basu, 'Personal Interviews'). As Assistant Director General of Health (Smallpox) at the DGHS, he was the executive head of the National Smallpox Eradication Programme of the Government of India. In the course of many sittings, he shared his experience in a mode that was remarkably at variance with either Dr Dutta, or Dr Tiwari, who will soon appear in the narrative. The significance of these differences in style will be currently explored. Meanwhile, I must thank him for making us feel always welcome and the warmth with which both he and Dr Tiwari gave of themselves.
29. Basu et al., The. Eradication of Smallpox, p. 49.
30. Foege, Strategies.
31. Ibid., p. 120.
32. Ibid., p. 122.
33. Ibid., p. 120.
34. Dutta, 'Personal Interviews'.
35. Foege, Strategies, p. 122.
36. Ibid., p. 119.
37. Ibid., pp. 119-120.
38. Brilliant, The Management of Smallpox, p. 134.
39. Kim Pelis, 'The Legacy of Jenner: Vaccination Past, Present and Future', Journal of the Royal College of Physicians of London, Vol. 30(6), 1996, p. 574.
40. K.M. Lal, National Smallpox Eradication Programme of India, New Delhi, 1966.
41. Basu et al., The Eradication of Smallpox, pp. 29-30.
42. Basu, 'Personal Interviews'.
43. I b i d.
44. Basu et al., The Eradication of Smallpox, p. 138.
45. Ibid., p. 120 and Figures 6.3 and 6.4.
46. Brilliant, The Management of Smallpox, p. 55.
47. This system of rewards began as early as 1969 in the so-called smallpox 'free' states that were reporting a low incidence of smallpox or sending in a 'nil' report' (Basu 1979: 115), both to indicate that it was rewarding to report and to ensure that they did report.
48. Please see the search protocol in Basu (Basu, The Eradication of Smallpox, p. 141).
49. Basu, The Eradication of Smallpox, p. 123.
50. Brilliant, The Management of Smallpox, p. 56.
51. I b i d.
52. Dutta, 'Personal Interviews'.
53. I.C. Tiwari, 'Personal Interviews', New Delhi, 1996.
54. Dutta, 'Personal Interviews'.
55. I b i d.
56. Pelis draws our attention to the fact that after the French revolution, and the collapse of the Faculties, the 'revolutionaries saw inoculation as eminently popularisable, a procedure that all citizens might perform preferably on each other' (Kim Pelis, 'State Medicine and Pharmaceutical Production in France'. Paper presented at the workshop on Immunisation and the State, at the Centre for Development Economics, Delhi School of Economics, Delhi, 16-17 January 1997, p. 4). The hiring and training of local youth to act as enumerators and vaccinators-'trained in 20 minutes'-seems to evoke this momentary dream of the late eighteenth century. The lie to this is offered by Paul Greenough in his 'Intimidation, coercion and resistance in the final stages of the South Asian Smallpox Eradication Campaign, 1973-1975', Social Science and Medicine, Vol. 41, No. 5, pp. 633-45, 1995. Greencugh (and others in that special issue) details a number of such stand-offs, with an extreme case being the one that Dutta refers to (see p. 450 further on) of an entire tribal village being cordoned off. But this 'dual' mode of arcadia and violence, and the necessary gloss, points to the fact that for an operation of this scale, local participation, whatever the modalities of enlisting it, was an important and crucial element.
57. Pelis draws our attention to the fact that after the French revolution, and the collapse of the Faculties, the 'revolutionaries saw inoculation as eminently popularisable, a procedure that all citizens might perform preferably on each other' (Kim Pelis, 'State Medicine and Pharmaceutical Production in France'. Paper presented at the workshop on Immunisation and the State, at the Centre for Development Economics, Delhi School of Economics, Delhi, 16-17 January 1997, p. 4). The hiring and training of local youth to act as enumerators and vaccinators-'trained in 20 minutes'-seems to evoke this momentary dream of the late eighteenth century. The lie to this is offered by Paul Greenough in his 'Intimidation, coercion and resistance in the final stages of the South Asian Smallpox Eradication Campaign, 1973-1975', Social Science and Medicine, Vol. 41, No. 5, pp. 633-45, 1995. Greencugh (and others in that special issue) details a number of such stand-offs, with an extreme case being the one that Dutta refers to (see p. 450 further on) of an entire tribal village being cordoned off. But this 'dual' mode of arcadia and violence, and the necessary gloss, points to the fact that for an operation of this scale, local participation, whatever the modalities of enlisting it, was an important and crucial element.
58. Basu, 'Personal Interviews'.
59. Dutta, 'Personal Interviews'.
60. I b i d.
61. Basu et al., The Eradication of Smallpox.
62. Tiwari, 'Personal Interviews'.
63. Basu et al., The Eradication of Smallpox, p. 217.
64. Ibid., p. 220.
65. Ibid., p. 222.
66. I b i d.
67. Ibid., pp. 222-23.
68. Tiwari, 'Personal Interviews'.
69. Basu et al., The Eradication of Smallpox.
70. Dutta, 'Personal Interviews'.
71. Dutta, 'Personal Interviews'.
72. Brilliant, The Management of Smallpox, p. 87.
73. I b i d.
74. Dutta, 'Personal Interviews'.
75. I b i d.
76. I b i d.
77. I b i d.
78. Brilliant, The Management of Smallpox.
79. I b i d.
80. A. Misic, 'Yugoslavia: Last Flare-up in Europe', Swasth Hind, Vol. XIX(4), pp. 125-29.
81. Georges Canguilhem, Ideology and Rationality in the History of the Life Science, Cambridge, Massachusetts, 1988.
82. Brilliant, The Management of Smallpox, p. 115. The model of triage is the quintessence of a 'vertical programme'. For a larger implication of the notion, see Shiv Visvanathan's 'On the Annals of the Laboratory State', in Ashis Nandy, ed., Science, Hegemony and Violence: A Requiem for Modernity, Delhi 1989, pp. 257-88.
83. Brilliant, The Management of Smallpox, p. 115. The model of triage is the quintessence of a 'vertical programme'. For a larger implication of the notion, see Shiv Visvanathan's 'On the Annals of the Laboratory State', in Ashis Nandy, ed., Science, Hegemony and Violence: A Requiem for Modernity, Delhi 1989, pp. 257-88.
84. Harish Naraindas, 'Poisons, Putrescence, and the Weather: A Genealogy of the Advent of Tropical Medicine', Contributions to Indian Sociology (n.s.), Vol. 30(1), 1996, pp. 1-35.
85. Toni Morrison, Playing in the Dark: Whiteness and the Literary Imagination, Cambridge, Massachusetts, 1990.