International Health and the Limits of its Global Influence: Bhutan and the Worldwide Smallpox Eradication Programme.

2013·0.41 MB·English

by  Bhattacharya, Sanjoy

Med.Hist.(2013),vol.57(4),pp.461–486. (cid:13)c TheAuthor(s)2013.PublishedbyCambridgeUniversityPress
2013.TheonlineversionofthisarticleispublishedwithinanOpenAccessenvironmentsubjecttotheconditions
oftheCreativeCommonsAttributionlicence<http://creativecommons.org/licenses/by/3.0/>.
doi:10.1017/mdh.2013.63
International Health and the Limits of its Global
Influence: Bhutan and the Worldwide Smallpox
Eradication Programme
SANJOYBHATTACHARYA∗
DepartmentofHistoryandCentreforGlobalHealthHistories,UniversityofYork,Heslington
Campus,
YorkYO105DD,UK
Abstract: Histories of the global smallpox eradication programme
have tended to concentrate on the larger national formations in Africa
andAsia.Thisfocusisgenerallyjustifiedbychroniclersbythefactthat
theselocationscontributedamajorshareoftheworld’sannualtallyof
variola,whichmeantthatinternationalagenciespaidalotofattentionto
workingwithofficialsinnationalandlocalgovernmentonanti-smallpox
campaignsintheseterritories.Suchhistoriographicaltrendshaveledto
themarginalisationofthehistoriesofsmallpoxeradicationprogrammes
in smaller nations, which are presented either in heroic, institutional
tropes as peripheral or as being largely shorn of sustained campaigns
against the disease. Using a case study of Bhutan, a small Himalayan
kingdom sandwiched between India and China, an effort is made
to reclaim the historical experiences in small national entities in the
worldwidesmallpoxeradicationprogramme.Bhutan’sexperienceinthe
1960s and 1970s allows much more in addition. It provides us with a
better understanding of the limited powers of international agencies in
areas considered politically sensitive by the governments of powerful
nations such as India. The resulting methodological suggestions are of
widerhistoricalandhistoriographicalrelevance.
Keywords: Bhutan, World Health Organization, Smallpox
eradication,Vaccination,Internationalhealth,India
Introduction
The worldwide programme to eradicate smallpox started gathering momentum in the
latterhalfofthe1960s,afterthecreationofanenergeticcoordinatingbodyattheWorld
HealthOrganizationheadquartersinGeneva(WHOHQ).Thisofficewasabletomobilise
unprecedentedlevelsofpoliticalandfinancialsupportinternationally.Whilstthesuccesses
in Western Africa had raised the profile of the fight against the disease in administrative
∗Emailaddressforcorrespondence:[email protected]
IamgratefultoAlexanderMedcalf,MargaretJones,MonicaSaavedraandtheanonymousrefereesfortheir
comments.However,Ialoneamresponsiblefortheviewsexpressedinthispaper.Researchforthisarticlewas
carriedoutwiththehelpofagrantawardedbytheWellcomeTrust,UK(Ref:077551);Iremaingratefulforits
support.
462 SanjoyBhattacharya
circleswithintheUnitedStatesofAmerica,itwasobvioustoalmosteveryonesupportive
of smallpox eradication that a genuinely global effort would need to be rooted in the
SouthAsiansubcontinent;herecountriessuchasIndia,PakistanandBangladeshregularly
contributedthebulkoftheworld’scasesofvariola.1 TheWestAfricancampaign,which
was coordinated by the United States Centers of Disease Control (CDC) and supported
by the United States Agency for International Development (USAID), coincided with
efforts to crank up the effectiveness of existing smallpox eradication programmes in
South Asia (activities that were spurred on by funds provided by the WHO and the
governmentsofIndiaandPakistan).ThisincludedsomesuccessfulpilotprojectsinIndia
with support from its federal and state governments; it is, therefore, difficult to make
definitivestatementsaboutwhetheroneregionalcampaignhelpeddevelopanother,even
ifsomeinstitutionalhistoriesandmemoirsseemextraordinarilyconfidentintheirclaims
inthisregard.2
WithDonaldA.HendersonasDirector,theWHOHQ-basedcoordinatingunitentered
into detailed negotiations with national governments across the world. The support
mobilised ebbed and flowed over time, and this experience presented WHO officials
with a steep learning curve, and forced them to face up to several harsh lessons about
the complexity of local administration and politics. These experiences, as well as the
difficultiescreatedbylargelyautonomousWHORegionalOfficesthatweredividedabout
thewisdomofprovidingunquestioningbackingtothegoalofsmallpoxeradication,helped
Henderson’s unit recognise the need to remain adaptable towards the crystallisation of
multifaceted national programmes.3 This enabled his associates and him to advocate a
lesstop-downstyleofmanagement,whichwaswelcomedatleastbysomeinternational
workers deployed by the WHO worldwide. These were WHO nominees who had been
consistently open to exchanging ideas with medical, paramedical and health officials
responsible for running local administrative structures; people who generally refused to
make rash presumptions about the abilities and attitudes of governmental staff, chose
their local allies carefully and were adept at fostering community stake-holding. New
and more reliable information flows about the actual levels of smallpox incidence were
aresult,whichhelpedtheproductionofamoreaccuratepictureofthechallengesfacing
theeradicationprogrammeinmyriadlocales.Whereimplemented,thesepoliciesallowed
1ForahistoricalexplicationthatmovesfromdescribingoriginsinEdwardJenner’sdiscoveryofasmallpox
vaccinein1796,toadvancesinsmallpoxcontrolwithinthePanAmericanHealthOrganisationregion,followed
by a cursory reference to the WHO and India, and then to a detailed treatment of the Western and Central
Africansmallpoxeradicationprogrammes,seeWilliamH.Foege,J.D.MillarandD.A.Henderson,‘Smallpox
EradicationinWestandCentralAfrica’,BulletinoftheWorldHealthOrganization,52(1975),209–22.
2ThisinterpretationofhistoricalprogressionappearslargelyundiminishedinFoege’srecentmemoir,although
thebookdoesacknowledgetheimportanceofthecampaignsinSouthAsia.SeeWilliamH.Foege,Houseon
Fire:TheFighttoEradicateSmallpox(Berkeley,CA:UniversityofCaliforniaPress,2011).TheCDCwere,of
course,alsoinvolvedinEastPakistan,butthisseemstobeignoredordownplayedintheheroictropesabout
itscontributionstosmallpoxeradication.ForamasterfultreatmentoftheCDC’sworkersinSouthAsia,see
PaulGreenough,“‘AWildandWondrousride”:CDCFieldEpidemiologistsintheEastPakistanSmallpoxand
CholeraEpidemicsof1958’,Ciencia&SaudeColetiva,16,2(2011),491–501.
3Things are rather more complicated in relation to histories of the West African – and other regional
–programmesthatinvolvedHendersonasanauthor.IntheWHO’sofficialhistory,ofwhichhewasco-author,
ananalysisoftheWesternandCentralAfricanprogrammeappearsintheseventeenthchapter,afterdescriptions
ofwhathappenedinSouthAmerica,Indonesia,AfghanistanandPakistan,Indiaand‘theHimalayanarea’and,
not least, Bangladesh. See F. Fenner, D.A. Henderson, I. Arita, Z. Jezek and I.D. Ladnyi, Smallpoxandits
Eradication(Geneva:WHO,1988).Inhisrecentmemoir,theAfricancasestudyappearsinthefifthchapter,
afteranassessmentofBrazilandIndonesiaandbeforeananalysisofIndiaandNepal.SeeD.A.Henderson,
Smallpox:TheDeathofaDisease(Amherst,MA:PrometheusBooks,2009).
BhutanandSmallpoxEradication 463
for the more efficient distribution of personnel, vaccines and funds; despite the ups and
downsofindividualprojects,thesetrendscontributedsignificantlytothefallsinsmallpox
incidenceacrossSouthAsiathatwerewitnessedbetween1970and1975.4
However,itwouldbeincrediblysimplistictoassumethatthesechangeswereembraced
both universally and uniformly, and that all international workers behaved in the same
way;liketheeffortsoftheirgovernmentalcounterparts,theworkcarriedoutbyoverseas
personnel was marked by varying levels of commitment, openness and efficiency. It is
also important to remember that the experiences within smaller nations in the South
Asian subcontinent such as Bhutan, Nepal and Sri Lanka were rather different from
those witnessed in India and Bangladesh, which were major reservoirs of the variola
virus. Specificities in relation to geographical factors, national politics, international
pressures, social profiles, and infrastructural and economic conditions were important
determinantsofhowsmallpoxeradicationprogrammesweredevelopedandrun.Yet,there
is surprisingly little recognition of the distinctiveness of national and local campaigns
across the South Asian subcontinent in the generalising narratives available to us.5 In
relationtoBhutan,thefocusofthisarticle,itisworthnotingherethattheofficialWHO
historieshavestruggledtoprovidemorethanafewparagraphsorpagesonitsexperiences,
and that the accounts are not particularly fulsome. For instance, the flagship history of
theIndiancasestudypreparedbytheWHORegionalOfficeforSouthEastAsia(WHO
SEARO), which was published in 1979, manages to describe the entire history of the
kingdom’sprogrammeinthefollowingparagraph:
From1954to1965nosmallpoxcasewasreportedinBhutan.In1966fortycasesresultingin20deaths
were detected. This outbreak resulted from importation of infection among newly recruited labourers
coming from India. Apart from one importation in 1974, no other smallpox cases have been reported
duringtheperiod1967–75.Inviewoftherecentendemicityofsmallpoxinneighbouringcountriesandthe
relativelyfreemovementofthepopulationbetweenIndiaandBhutan,anintensifiedsmallpoxsurveillance
programmewasorganizedinthesecondhalfof1976.Inautumn1976,surveillanceactivitiesweremainly
concentratedintheupperandmiddlezones,includingsevenurbanareaswhereahouse-to-housesearch
for cases was organised together with a facial pockmark and vaccination scar survey. Weekly markets
were visited periodically and outbreaks of fever and rash were investigated. At the end of 1976 and
the beginning of 1977, surveillance activities were concentrated in the lower zone, bordering India. A
thoroughhouse-to-housesearch,coveringallvillagesandmunicipalities,wasorganizedandafacialpock
markandvaccinationscarsurveywascarriedout.Feverandrashrumourswerecollectedandsubsequently
verifiedbyexperiencedfieldworkers.AWHOInternationalCommissionconfirmedon22April1977that
smallpoxhadbeeneradicatedinBhutan.6
There is nothing unusual about the brevity and blandness of this analysis. The tone was
almostreplicatedinthemulti-authored,widelycelebratedofficialhistorytitledSmallpox
4AnexceptionallyhonestappraisaloffieldconditionsinSouthAsiaisprovidedinAlanSchnur,‘Innovation
asanIntegralPartofSmallpoxEradication:AFieldworker’sPerspective’,inS.BhattacharyaandS.Messenger
(eds),TheGlobalEradicationofSmallpox(NewDelhi:OrientBlackSwan,2010),106–50.Forafrankanalysis
oftheautonomyofitsRegionalOfficesandthewaysinwhichtheywereabletochallengetheWHOHQ,refer
totherecordingofalectureonsmallpoxeradicationbyD.A.Henderson,London,30May2007,availableat:
http://www.york.ac.uk/history/research/majorprojects/smallpox-eradication/audio/henderson/.
5WhilsttheexistingworkonIndiaandBangladeshrecognisesthemanycomplexitiesoftheconditionsonthe
ground,theydonotrefertotheconditionsexistinginthesmallerpoliticalunitsintheneighbourhoodorthe
effectsoftheinfluenceofonenationoveranother.See,forinstance,SanjoyBhattacharya,ExpungingVariola:
TheControlandEradicationofSmallpoxinIndia,1947–77 (New Delhi: Orient Longman, 2006) and Paul
Greenough,‘Intimidation,CoercionandResistanceintheFinalStagesoftheSouthAsianSmallpoxEradication
Campaign,1973–1975’,SocialScience&Medicine,41,5(1995),633–45.
6R.N. Basu, Z. Jezek and N.A. Ward, The Eradication of Smallpox from India (New Delhi: World Health
OrganizationSouthEastAsiaRegionalOffice,1979),93.
464 SanjoyBhattacharya
and its Eradication published by the WHO HQ in 1988. Numbering all of 1460 pages,
it devoted about four paragraphs and a few stray sentences to Bhutan, largely placed in
aconcisesectionthatalsodiscussedthesituationprevalentwithinthekingdomofNepal
andtheIndianprotectorateofSikkim(thelatterbecameaformalpartoftheRepublicof
Indiain1975).ThepottedhistoryoftheBhutaneseprogrammeprovidedbythefollowing
paragraph gives us an effective appreciation of the limited scope of this retrospective
officialanalysis:
Until1961,nohealthdepartmenthadbeenestablishedinthecountry.In1964,thegovernmentcreated19
postsforvaccinators,andincreasedthenumberto25in1966,whenamassvaccinationcampaignwas
begunfollowinganoutbreakof74casesofsmallpoxin1965–1966inthecapitalcityofThimbu[sic].
TheoutbreakhadbegunamongIndianandNepaleseworkersemployedinaroad-buildingprojectand
thenspreadtothelocalpopulation.Thenumberofvaccinationsreportedtohavebeenperformedbetween
1967and1975,however,wassmallinrelationtothepopulationof987,000(1967estimate).Afterthe
1965–1966outbreak,only4furtheroutbreakswerereported.In1967,2outbreaksoriginatinginAssam
caused14cases.Thethirdoutbreak,of6cases,occurredinApril1973inavillagenearthesouth-western
borderwithIndia,theinitialcasehavingbeeninfectedonateaestateinWestBengal.Thefourthoutbreak,
nearthesameborderarea,occurredinFebruary1974andconsistedof3cases,ofwhichthefirsthadbeen
infected in Assam. Surveys conducted in 1976 to detect individuals with facial pockmarks, as well as
interviewswithvillageofficials,indicatethatother,unreportedoutbreakshadoccurredalthoughnonehad
producedmorethanafewcases.Thiswasattributedinparttothefactthatthevillageswerescatteredand
isolated,andinparttothesensibletraditionalpracticeofisolatingthepatientandhisfamilyattheonset
ofillnessinaplacesomedistanceawayfromthevillage.Inthesecircumstances,thespreadofsmallpox
wasdifficult.7
These official narratives provide the strongest possible justification for the preparation
of an alternative, more complex analysis of Bhutan’s national smallpox eradication
campaigns and the many ways in which they were linked to the worldwide programme
targetingvariola.Themosteffectivemeansofdoingthisisbyusingarangeofunpublished
documentationthathasbeenstoredawayintherecessesoftheWHOarchivesinGeneva,
a large proportion of which has not been assessed critically before; these papers are
important because they allow us to focus on debates and discussions that were largely
carried on away from the public gaze. For our purposes here, it is useful to analyse an
expansivesetofconversationsinvolvingavarietyofactors:thesmallpoxeradicationunit
within the WHO HQ in Geneva, a group of well-connected medical volunteers based in
theUSA,theroyalcourtandgovernmentofBhutaninThimpu,theWHOSEAROoffices
inNewDelhiand,notleast,theIndianfederalauthoritiesandtheirrepresentativesinthe
Himalayankingdom.
OpeningUp
LandlockedbetweenIndiaandChina,theHimalayankingdomofBhutanhasalwayshad
enormous strategic importance for these politically and militarily ambitious neighbours.
However, India benefited from treaties negotiated during British colonial rule, which
allowed it to retain prolonged control over Bhutanese foreign and defence affairs. This
arrangementwasformalizedinAugust1949,ameretwoyearsafterIndianindependence,
through an Indo-Bhutanese Accord; this agreement allowed for the return of territories
annexed by the British empire and the provision of annual subsidies by the Indian
authorities to the kingdom (the terms of this Accord were only renegotiated as recently
asFebruary2007,whenBhutanwasallowedanincreasedsayinitsownexternalaffairs
7Fenneretal.,SmallpoxanditsEradication,802.
BhutanandSmallpoxEradication 465
and defence procurement policies). The 1949 treaty was intended to officially enshrine
an arrangement whereby India did not interfere in Bhutan’s internal affairs, in return
for which New Delhi was given overall control of the kingdom’s foreign relations (this
included an agreement that nations represented on the UN security council would not
be allowed to open diplomatic missions in Thimpu). In practice, however, both parties
struggled to honour this delineation of responsibilities and the resultant tensions were
visiblefromasearlyas1952,theyearareformistmonarch–KingJigmeDorjiWangchuk
–ascendedtotheBhutanesethrone.Someoftheseclasheswerestokedbyactsattributable
toinfluentialindividualssuchasJawaharlalNehru,India’sfirstprimeminister.TheBhutan
State Congress (BSC), a new political party, was formed in India in 1952 with Nehru’s
patronage; however, it was banned soon afterwards by the kingdom’s government, as it
wasaccusedofbeingdominatedbyalargelyNepalesemembershipdrivenbysecessionist,
anti-monarchicalideologies.8
Bhutan’s monarch created a partially elected National Assembly in its stead in 1953,
butthisdidnotreininthecountry’spoliticaltroubles.TheproscribedBSCcontinuedto
be a political force, especially amongst the Nepali-speaking sections of society fighting
foraccesstofullcitizenship;itremainedpowerfulenoughin1954tosuccessfullycallfor
anationwidecivildisobediencemovement,whichcausedanofficialcrackdownthatledto
thedeathofabout25protestors.TheIndiangovernmentinsistedoninterveningtoresolve
theresultantcrisis,brokeringanuneasydealwherebythekingdom’sgovernmentpromised
topassanewCitizenshipLawin1958thatprovidedBhutanesecitizenshiptoatleastsome
residentsofNepaleseorigin.9Ethnicrelationscontinuedtobefrailinthekingdomdespite
these legal advances and this was exposed by political developments that affected the
region in 1959, following the entry of Chinese troops into Tibet (this correlated with an
increase in covert activities by American and Indian intelligence agencies in Himalayan
SouthAsia).10 AlthoughseveralthousandTibetanrefugeesweregivenasyluminBhutan
that year at India’s insistence, this influx was considered to be socially and politically
destabilising.TheresultwasanewlawpassedbyBhutan’sNationalAssembly,banning
further immigration from Tibet into the country.11 The Sino-Indian conflict of 1962
affectedthekingdomdeeplyinasituationwheretheretreatingIndianarmydetachments
useditsterritoriesasoneofitsescaperoutes.China’sresoundingvictoryinthewarcaused
astiffeningofIndianandBhutaneseattitudestowardstheirnorthernneighbour,leadingto
8For an effective treatment of the formation, composition and activities of the BSC, see Awadesh Coomar
Sinha,HimalayanKingdomBhutan:Tradition,TransitionandTransformation(NewDelhi:Indus,2001).Afull
transcriptoftheIndiaBhutanFriendshipTreatyof2007isavailableat:http://www.satp.org/satporgtp/countries/
india/document/papers/indiabhutan.htm(accessedon2May2012).
9Michael Hutt, ‘Being Nepali without Nepal: reflections on a South Asian diaspora’, in D.N. Gellner,
J. Pfaff-Czarnecka and J. Whelpton (eds), Nationalism and Ethnicity in a Hindu Kingdom: The Politics
of Culture in Contemporary Nepal (Amsterdam: Harwood Academic Publishers, 1997), 101–44. For a
more charitable, uncritical but detail-rich assessment of Tibetan enclaves inside Bhutan, see ‘Tibetan
Settlements – Bhutan’, Department of Home, Central Tibetan Administration, Dharamshala, India, at:
http://www.centraltibetanreliefcommittee.org/settlements/bhutan/settlements-in-bhutan.html (accessed on 26
December2012).
10A detailed assessment of US and Indian alliances in relation to covert intelligence in Himalayan South
Asia,includingterritorieswithinnorth-easternIndia(SikkimandtheNorthEasternFrontierAgency/Arunachal
Pradesh),NepalandBhutanisavailableinKennethConboyandJamesMorrison,TheCIA’sSecretWarinTibet
(Lawrence:UniversityPressofKansas,2002).
11For a detailed analysis of ethnic politics in Bhutan and Nepal, see Michael Hutt, Unbecoming Citizens:
Culture,Nationhood,andtheFlightofRefugeesfromBhutan(NewDelhi:OxfordUniversityPress,2003).
466 SanjoyBhattacharya
themilitarisationofBhutan’snorthernbordersadjacenttoTibet;thissharedfearoffurther
invasions also contributed to Bhutan joining the Colombo Plan treaty in 1962, as this
assertion of national sovereignty was seen as providing at least some level of protection
fromafutureChineseforayintothekingdom.12
It is against this complex and unstable political and social backdrop that negotiations
were started between the Bhutanese royal court and Dr Pierce Gardner, who was an
AssistantProfessorofMedicineattheUniversityofFlorida,USA,in1969.Onthetable
wasaschemethatwouldhelpdevelopthenation’sstate-sponsoredhealthservices.These
engagementswereverymuchinkeepingwiththekingdom’seffortsatthetimetoopenup
totheworld,albeitundertheclosescrutinyoftheIndiangovernment.Bhutanhadsigned
uptotheColomboPlantreatybeforehand,butmuchoftheaidprovidedunderthisscheme
forthebuildingofhealthinfrastructuresuchashospitalswasprovidedbyIndia.Theroyal
government’snegotiationswithGardnerwerenovelpreciselybecausetheydealtwithaset
ofpeoplenotformallyassociatedtoaCommonwealthnation.Manychallengesbeckoned
for both parties, not least as the plans under deliberation could be latched on to existing
political and economic agreements; it was clear that such an unprecedented intervention
intoBhutan’shealthaffairswouldneedtobefundedbyexternalsources.Moreover,very
little independently verified information about healthcare structures and disease profiles
in Bhutan during the first six decades of the twentieth century was available at the
time; this situation was exacerbated by the fact that a major flood in 1967 that caused
the wide-ranging destruction of relevant government records. The sprinkling of extant
publications on the theme of medicine and health in Bhutan tended to rely on the use
of piecemeal information provided by the Bhutanese authorities as a result. We can see
such interpretative tendencies in an article in the Lancet, which was published in 1965;
authoredbyacoupleofseniorBritishmedicalpractitioners,whowerepossiblygivensome
independent access to Thimpu because the United Kingdom was an important signatory
of the Colombo Plan treaty, the article was largely uncritical about figures provided by
Bhutan’shealthministry.13
This is what makes the records resulting from Dr Pierce Gardner’s engagements with
Bhutan’s royal court both fascinating and important. As Gardner entered into detailed
negotiationswiththeBhutaneseauthorities,aboutaschemetitled‘PartnershipforMedical
Progress’, he was presented with an opportunity to access and accumulate significant
bodies of data about healthcare trends in the Himalayan kingdom. Fortunately for us,
Gardneracceptedthatopening;evenmorepropitiously,perhaps,hechosetosharethese
datasetswithDonaldHenderson’sofficeinGeneva,whichfiledthepapersawaycarefully
(as it transpires, for long-term use by researchers who choose to study the WHO’s
voluminous smallpox eradication archives). Gardner’s access to the royal family, which
seems to have been sparked by the fact that he had worked in CDC-led projects outside
12R. Kharat, ‘Indo-Bhutan relations: strategic perspectives’, in K. Warikoo (ed.), Himalayan Frontiers of
India: Historical, Geo-political and Strategic Perspectives (Abingdon: Routledge, 2009), See also Bhutan:
ForeignPolicyandGovernmentGuide:Volume1:StrategicInformationandDevelopments(WashingtonDC:
InternationalBusinessPublications,2011).
13MichaelWardandFredericJackson,‘MedicineinBhutan’,Lancet,285,7389(1965),811–3.Recenthistorical
scholarshiponBhutan’shealthservicesanddiseaseprofileshasbeenmainlydependentontheretrospective
recollections, published or otherwise, of an extremely small sample of people who have been identified by
asmajorfiguresinBhutanesemedicineandpublichealth.Thesememories,whichhavebeengleanedmainly
throughaseriesofundemandinginterviews,areusuallyreporteduncritically.Forarepresentativeexample,see
AlexMcKay,TheirFootprintsRemain:BiomedicalBeginningsacrosstheIndo-TibetanFrontier(Amsterdam:
AmsterdamUniversityPress,2007).
BhutanandSmallpoxEradication 467
the USA and was seen to have connections with managers of international programmes,
ensuredthatinformationabouthealthtrendsinBhutanwascarefullycollectedforhimby
regaldecreefromavarietyoflocalities;thismaterialwasvoluminousandrichindetails
about the district-wise breakdown of disease affecting the kingdom’s population. It was
not,byanymeasure,anexerciseintendedtopresentanidealisedimageofthehealthiness
oftheBhutanesepopulation.Eventhen,Gardnerdidnotacceptthesedatasetsblindly.He
instead chose to cross-reference this information with figures available to him in reports
andpapersaboutColomboPlan-fundedprojectsinthekingdom,andthencameupwith
blunt assessments about the gaps in state-sponsored healthcare delivery. He noted, for
instance,that:
Accordingtothelatestfigures,DrTobegeyal[sic]hasavailableonlyahandfuloftrainedphysiciansplus
25compounders(workerswithtwoyearsofmedicaltraining)toassisthiminprovidingmedicalcarefor
theentirenation–800,000peoplescatteredoveranareaof18,000squaremiles.Evenso,togetherthey
havebeenabletostaffthecountry’sfourhospitals,withatotalbedcapacityof120,andthedispensaries
locatedineachofthe23dzongs,ormaindistrictsofBhutan.Whilesignificantprogresshasbeenmade
inimprovingthehealthcareavailableinthecountry,thesmallnumberofmedicalpersonnelandfacilities
stillrestrictsmedicalservicesinBhutan.14
Gardner also mentioned India’s great influence on Bhutan’s public health agendas,
noting that Dr P.D. Gogoi, an Indian physician, headed the relevant federal department.
He made reference to a number of active health projects, but specially mentioned the
significanceaccordedtomalariaeradicationworkthatwasfinancedbyIndiaandfocused
on the Phuntsholling area in the southern part of the country. In relation to smallpox
immunisation programmes, Gardner wrote about 20 vaccinators who were employed by
thegovernmentafteramajorvariolaoutbreakin1966(theirworkwasmainlytargetedat
the areas to the west of the Black Mountains).15 He flagged up data that showed that
diphtheria, pertussis and BCG vaccines were available in dispensaries, but there was
little evidence to show that routine preventive work was carried out in relation to these
diseases.Sexuallytransmitteddiseases,aswellashealthproblemscreatedbywormsand
diarrhoea, were widely prevalent in the kingdom.16 Gardner also mentioned campaigns
against goitre, which were discontinued for a couple of years due to unspecified socio-
political problems.17 Data available to him revealed that the anti-goitre work was based
onthegeneralintroductionofiodizedsalt.18
Thesedetailsprovidedallthepartiesinvolved–DonaldHendersonandhiscolleagues
inWHOHQincluded–withinsightsintotheworkingsofacountryaboutwhichverylittle
wasknownwithinthewidercommunityofinternationalhealth.Thematerialswerewide-
ranginganddetailedenoughforGardnertotabulatefigures,formulategeneralisations,set
targetsandforwardproposalsforcollaborationtotheWHOHQ.Theschemehesuggested
toHendersonwasabroad-rangingone,aswecanseefromanextractdrawnfromoneof
hisdraftplans:
In paving the way for improved, long-term health standards...[mobile health] teams have been more
effectivewhenactinginpartnershipwithindigenouspersonnelincarryingoutaspecifichealthproject....
14PieceGardner,‘PartnershipformedicalprogressinBhutan’,nodate,3,Folder55,Box184,WorldHealth
OrganizationHeadquartersArchives,Geneva(WHOHA).
15PierceGardner,‘SupplementReport–BHUTAN’,c.1969,Folder55,Box184,WHOHA.
16AseasonalincreaseindiarrhoeawasreportedbetweenthemonthsofMayandJuly.Gardner,‘Supplement
Report’,WHOHA.
17Ibid.
18Gardner,‘PartnershipformedicalprogressinBhutan’,3,WHOHA.
468 SanjoyBhattacharya
It is clear...awareness of and desire for public health programs exist in Bhutan. But the forceful
prosecutionoftheplans...require[s]amoreeffectivedeliveryofmedicalcarethanthatcurrentlyavailable
intheKingdom.Webelievethatevenasmallnumberofmedicalpersonnel,iforganizedintomobilehealth
teams,canhelpBhutanachieveamorecomprehensiveprogramofdiseasepreventionandpublichealth
education.Hence,weproposetomakeavailabletotheKingdomofBhutanphysiciansandparamedical
personnelforthepurposeofdemonstratingthepracticabilityanddesirabilityofsettingupsuchmobile
healthteams.19
The scheme was to be built around the establishment of three teams, each composed
of members of Gardner’s American colleagues working alongside Bhutanese personnel.
Smallpoxvaccinationwasintendedtobetheprimaryfocusoftheprogramme,asGardner
andhiscolleagueshopedthatthesewerelikelytodevelopintoaseriesoflocallysupported
projects over the long term. The entire activity was planned for March, April and May
1970;thiswastoincludeatwo-tothree-weektrainingstintinthecitiesofThimpuorParo
aimed at creating synergies between overseas and local team members. The expectation
was that the success of this pilot would cause immunisation services to be included
in wider, more permanent mobile disease prevention campaigns.20 Gardner hoped that
financialsupportfortheplannedschemewouldbeprovidedbynon-governmentsources
such as private foundations and non-profit organisations; he did not intend to ask the
Bhutanese government for financial contributions and expected its role to be limited
to employing the local personnel who would join the mobile health teams and provide
donationsofequipment(intheshapeofavehicleandsomecampingequipmentforeach
team).21 Thecostscalculatedforthepartnership,outlinedinminutedetailbyGardnerin
adocumenttitled‘SupplementReport–Bhutan’,werenotenormousbythestandardsof
the time for international collaborative efforts launched in developing countries: a most
carefully calculated sum of US$26,814.80. Considered valuable by King Jigme Dorji
WangchukandPrinceNamgyalWangchuk,thelaunchoftheschemewasformallyinvited
frombytheBhutanesegovernmentinJune1969.22
A letter from Bhutan’s Ministry of Trade, Commerce and Industries to Gardner that
month informed him that the expectation was that the proposed project would continue
foratleasttwelveweeks,thatthemaingeographicalfocusoftheteamswouldbecentral
Bhutan, that the costs of travel to the Kingdom and local maintenances expenses would
have to be met by the team itself, and that the arrangements for vaccine and medical
supplies would also need to be their responsibility. In return, the Bhutanese authorities
offered to supply vehicles and fuel for travel, and enlist compounders, medical and
paramedical personnel to become members of the proposed mobile teams.23 It was now
timeforGardnertoturntoDonaldHenderson,withwhomhehadadiscussionpreviously
about his plans at an Epidemic Intelligence Services meeting at the CDC offices in
19Ibid.,1–4,WHOHA.ApartfromGardner,theproposedteamwastoincludeMsJoAnnSilverstein(aUS
citizen trained in French, government studies and mathematics), Dr Samuel Silverstein (a US citizen then
Assistant Professor at the Department of Cellular Immunology, Rockefeller University, New York, and Jo
AnnSilverstein’shusband)andDrMichelBernardVallotton(aSwisscitizenwhowasthenChefdeClinique
ScientifiqueattheCliniqueuniversitairedeMedecineetLaboratoiredePhysiopathologieCliniqueinGeneva).
Appendixtoibid.
20Ibid.,5–6.
21Ibid.,6–7.
22Gardner,‘SupplementReport’,WHOHA.
23Letternumber2–10(TCI)/69toP.Gardner,CampThimpu–Bhutan,fromMinisterforTrade,Commerceand
Industries,16June1969,Folder55,Box184,WHOHA.
BhutanandSmallpoxEradication 469
Atlanta,forassistance.Thecorrespondencebetweenthetwomentellsusalotaboutthe
complexitiesbedevillingthesmallpoxeradicationprogrammeandthewiderinternational
health landscape; features that we would never be aware of without careful primary
researchintheavailablearchives.
AStuntedForay
Bhutanstartedtoupgradeitssmallpoxcontrolfacilitiesaroundthemid-1960sinresponse
to a series of outbreaks linked to Indian workers employed in road building projects
across the kingdom.24 Very little seems to have been known about these immunisation
efforts within WHO HQ and WHO SEARO for the bulk of the decade, due mainly to a
cultureofsecrecyrelatingtotheadministrationofBhutanthatwasjealouslyguardedby
the Indian government; a state of affairs that United Nations (UN) agencies, including
the WHO, could do little to change (Bhutan only joined the UN in 1971). However,
PierceGardner’scorrespondencebegantoprovideDonaldHendersonandhisteamwithin
the WHO HQ with unprecedented detail about variola incidence in the kingdom. In a
letter to Henderson, sent in April 1969, Gardner repeated that he had been invited by
the Bhutanese royal family to start a medical programme that was tentatively slated for
the spring of 1970. The missive made a case for an assessment of the effectiveness of
mobile health teams, mainly as Gardner noted that data available to him showed that
Bhutan had limited numbers of medical personnel and that it was important to provide
immunisation facilities outside urban areas. As an avid advocate of preventive health,
he wondered if an immunisation campaign against smallpox might be made the central
partoftheplannedproject.Atthesametime,Gardneralsohighlightedhissupportfora
suggestion made by Henderson during their talks in Atlanta that the smallpox and BCG
vaccinesbeadministeredsimultaneouslyinBhutan.Headdedthat:
Igreatlyappreciateyourofferofsupportintheformofvaccineandintermsofpossiblefutureconsultation.
Wearecurrentlyinthefundraisingstage,approachingvariousfoundationsanddrugcompanies.Itwould
behelpfultohavealetterfromWHOstatingthatthisprojectisinkeepingwiththegoalsoftheWHO
eradicationprogram,thatitisascientificallysoundprogramandthatyouwouldencourageitssupport.I
alsoplantocontactUNICEFconcerningthepossibleuseofBCGintheprogram.
Gardnersignedoffhisletterwithahand-writtenpostscriptrequestinganoutlineofthepox
survey techniques that Henderson had mentioned in Atlanta as being useful for baseline
datagatheringinthesmallpoxeradicationprogramme.25
Gardnerpersisteddespitenotreceivinganimmediatereplyandshotoffanothermissive
to Henderson the following month. This letter underlined the point that he was poised
to make a preliminary visit to Bhutan in the first half of June and that he would be
presenting his programme proposals to the kingdom’s government. He requested the
name of the WHO SEARO representative who could be approached for assistance and
24TheBritishgovernmentanditsintelligenceservicesweremonitoringthepoliticalsituationinBhutanduring
thisperiod,notleastastheofferofmilitaryaidfromtheUKtothekingdomwasbeingconsidered.Foran
assessmentoftrendsbetween1959and1965,seeDO164/73,DO196/520andDO196/521,NationalArchives
ofBritain,Kew,UK(NAB).India’sdefeatinitswarwithChinaledtogreaterlevelsofUKandUSmilitary
assistance;seePREM11/4857,NAB.Thiscausedwiderregionaltensions,ofteninvolvingcountriessuchas
Pakistan,whichobjectedin1964and1965totheprovisionofthisaidtoIndiaandBhutan;seeDO164/134,
NAB.
25LettertoD.A.Henderson,Chief,SmallpoxEradicationUnit,WHOHQ,Geneva,fromP.Gardner,Assistant
ProfessorofMedicine,TheJ.HillisMillerHealthCenter,UniversityofFlorida,USA,23April1969,Folder55,
Box184,WHOHA.
470 SanjoyBhattacharya
asked,onceagain,for‘adescriptionofthescarsurveytechniquethatwasworkedoutin
West Africa’.26 This persistence paid off. In a personal letter, warm in tone, Henderson
apologised for the delay in replying, saying that he had been travelling constantly.
Henderson provided Gardner with Dr Jacobus Keja’s name as the person to contact
in relation to matters regarding smallpox eradication within WHO SEARO, which was
responsible for negotiations with the Bhutan government on health-related issues, and
enclosedthreecopiesoftheformsheusedforscarsurveys.Significantly,Hendersonalso
advised him about the importance of embracing techniques that had been developed for
useinsidetheregion,declaringthat:
Themethodologyemployedhasvariedratherconsiderablyfromcountrytocountryandwedonot,infact,
haveawrittenprotocolwithregardtomethodologyasitispresentlybeingapplied.Iwouldurgethatyou
talkfurtherwithDrKejaaboutthisfortheapproachwhichheisusinginSouth-EastAsiaappearstobe
bothsimpleandeffectivealthoughnotqualifyingasavalidstatisticalsamplewhichintroducesallsortsof
complexitiesinthedevelopingcountries.27
This was to be one of many reminders, from Henderson to outside observers, that
epidemiologicalmodelsthathadbeenadvertisedasbeingsuccessfulbysmallpoxworkers
involvedinWestAfricawerenotbeingblindlyutilisedindiseasehotspotssuchasSouth
Asia.Indeed,inthelate1960s,corestrategiesfordevelopingawholesomeunderstanding
ofsmallpoxincidenceinAsiawerebasedonanadaptablesetofscarsurveypoliciesthat
werevariouslyimplementedindifferentlocalities.HendersonalsounderlinedtheWHO’s
inability to disregard regional, national and local political frameworks during the design
and implementation of policy, even as he sought to assure Gardner that he would do his
besttomobilisethenecessarysmallpoxvaccineandbifurcatedneedles.Hendersonwas,
infact,quiteoptimisticinJune1969whenhedeclaredthat:
Inthesmallpoxeradicationprogramme,wearemosthappytohavetheparticipationofallwhomight
contribute to it. As you will undoubtedly understand, our relationships must ultimately be dealt with
throughtheindividualgovernments.Inorderforustoprovidevaccineandbifurcatedneedles,Iwould
needtohavearequestfromtheGovernmentofBhutan.Iwouldgatherfromyourletterthatthiswouldnot
beadifficultproblemtoarrangeinconsultationwiththem.Followingreceiptofarequest,arrangements
canbemadetodespatchbothvaccineandneedlesveryrapidly,althoughwhatsortoftransportisavailable
intoBhutanatthistime,Isimplydonotknow.Clearly,wecouldhavethenecessarysuppliesinDelhi
withinaperiodofaweek,asvaccineisstoredinGenevaalongwiththeneedles.28
Whilstacknowledgingtheimportanceofconsideringthepoliticalexpectationsofnational
governments, this correspondence revealed that Henderson had not been fully aware of
the diplomatic protocols in relation to dealings with Bhutan and India. He was soon
disabusedoftheviewthatitwasappropriatetodealwithThimpuwithoutWHORegional
Office participation. The evolution of Henderson’s understanding about the care needed
whilst dealing with Bhutan’s authorities is demonstrated most effectively through his
correspondence after Gardner reported an outbreak of about 2000 cases of smallpox in
1966; a detailed breakdown of cases had been provided to him by the Bhutanese health
26LettertoD.A.Henderson,Chief,SmallpoxEradicationUnit,WHOHQ,Geneva,fromP.Gardner,Assistant
ProfessorofMedicine,TheJ.HillisMillerHealthCenter,UniversityofFlorida,USA,19May1969,Folder55,
Box184,WHOHA.
27LettertoP.Gardner,AssistantProfessorofMedicine,TheJ.HillisMillerHealthCenter,UniversityofFlorida,
USA,fromD.A.Henderson,Chief,SmallpoxEradicationUnit,WHOHQ,Geneva,29May1969,Folder55,
Box184,WHOHA.
28LettertoP.Gardner,AssistantProfessorofMedicine,TheJ.HillisMillerHealthCenter,UniversityofFlorida,
USA,fromD.A.Henderson,Chief,SmallpoxEradicationUnit,WHOHQ,Geneva,19June1969,Folder55,
Box184,WHOHA.