Many cultures have believed that angry deities get their revenge by causing death and disease in humans. In India, smallpox was believed to be caused by Sitala-Mata, or Devi, the goddess responsible for pustular diseases.6 The strength of this belief is evident in historical documents. For example, Hindu residents of Kanpur wrote an appeal when the colonial government decided to make vaccination compulsory in 1888: “The major portion of our community believes that small-pox is the direct expression of the wrath of the Goddess Bhawani or Shitala. It is not a malady that can be cured by medicine, and any attempt to check its progress will only enrage the Goddess, who is otherwise pacified by prayers and simple diet. The belief is founded on sacred texts . . . and . . . we believe that our just Government will not offend the religious feelings of its loyal subjects.”7
The goddess was depicted in different forms and bears different names in different parts of the country. Because the annual increase in cases occurred in the springtime, in the eastern and northeastern regions the disease was called basonto (relating to the spring) or guti basonto (nodules appearing in the spring). In southern India, it was known as peria ammai or doddamma (big goddess) or vaisuri noi (disease with eruptions).
Figure 8. A village smallpox goddess (far less elaborate than was typical)
As India’s population density increased through the centuries, smallpox may have become an almost universal disease, a rite of passage, truly democratic in its disregard for caste or economic status. Cities were probably its major focus, especially during the low-transmission time of the year, during the monsoons. As travel increased again after the monsoons, the virus would be seeded to rural areas through commerce and family visits.
In India, as in Africa, variolation evidently existed for centuries, which meant that, religious beliefs notwithstanding, Indian society had long been aware that a simple operation could protect against smallpox. Holwell describes how a group of Brahmins traveled on a circuit to provide inoculations before the seasonal upswing of smallpox. They followed careful protocols, requiring an entire village to agree to inoculation before they would begin, and asking the village to remain isolated from other villages until the lesions had healed. Apparently the results were so good that the demand for variolation soon exceeded the Brahmin ability to respond. This led to an increase in the price charged for the procedure. The marketplace took over, less careful operators proliferated, entire villages were no longer inoculated at the same time, and outbreaks of smallpox resulted.8 During the early days of vaccination, variolators often resisted vaccination because it competed with their livelihood, although some readily transferred their skills and became vaccinators.
While there is no question that smallpox had a long history in India, its full impact is less clear. Early records on smallpox mortality are simply unavailable. During the colonial period, the British attempted to collect data systematically, but their statistics are open to interpretation. We know, for example, that seventy-five years after Jenner’s first vaccination in 1796, India recorded nearly two hundred thousand deaths in a single year. However, in that time of incomplete record keeping, the actual number had to be larger.
In 1883, in the single state of Uttar Pradesh, over 138,000 deaths were recorded; over 202,000 were recorded the following year. As the population of the state was then estimated at 5 million, these figures indicate that about 7 percent of the population of Uttar Pradesh died of smallpox during those two years. If mortality rates were about one-third, as they were in the twentieth century, it would appear that over 20 percent of the population of Uttar Pradesh acquired smallpox during that two-year span.9 This is without adjusting the numbers to allow for incomplete records.
It is easier to get accurate records for royal families. The history of the Tipparah royal family reveals that between the fifteenth and eighteenth centuries, five of the sixteen maharajas died of smallpox. Again using a mortality rate of about one-third, this suggests that all sixteen may have actually acquired the disease.10
EARLY VACCINATION EFFORTS
Vaccination efforts in India began almost immediately after Jenner’s discovery in 1796. In 1799, Jenner himself shipped copies of his paper and a quantity of cowpox material on the East India ship The Queen, but the ship was wrecked before reaching India.11 The vaccine finally made it to India three years later, after vaccination was successfully established in Constantinople and Baghdad. This strain of vaccine can be traced back to Jean de Carro from Vienna and from him to Luigi Sacco, who acquired it in 1800 from a herd of Swiss cows at a county fair near the border between Italy and Switzerland.12 Therefore, in the final analysis, it was Jenner’s idea but not his vaccine that started the program in India.
Spread of vaccine throughout the country was not simple. When attempts to ship dried cowpox material on cotton threads proved unsuccessful, the decision was made to deliver the virus from place to place through a series of children. As lesions developed in their skin, they in turn became the donor of virus to the next susceptible child, in this way maintaining a chain of viable cowpox virus propagated in human lymph. In Bombay, on June 14,1802, Dr. Helenus Scott successfully vaccinated the first child, a three-year-old girl, Anna Dusthall. From this child the vaccine virus spread outward from Bombay. Accounts exist that track its spread. For example, spreading the virus from Madras to Calcutta required five children and five weeks. On October 10, 1802, Dr. James Anderson vaccinated a thirteen-year-old boy, John Cresswell, using material from the vaccination of an Indian child. With Cresswell, Dr. Anderson boarded the ship Hunter. Twelve days later, Anderson vaccinated a girl using material from Cresswell’s lesion. On November 2, the fourth child, a boy, was vaccinated by using material from the girl’s lesion, and on November 12, a fifth child, a boy by the name of Charles Norton, was vaccinated. Norton became the source of vaccine for Calcutta when the ship arrived on November 17.13
British workers in India not only were some of the first to be vaccinated, but also were among the first to show their gratitude to Jenner. In May 1806, when the benefits of vaccination were still being argued in England, there was no confusion in the message sent along with a gift of £4,000 (a huge sum in those days) to Jenner from “the principal inhabitants of Calcutta and its dependencies as a testimonial of their gratitude for the benefits which this Settlement, in common with the rest of mankind, has derived from his inestimable discovery of a preventive of the smallpox.” The example of Calcutta was quickly followed by gifts from Bombay and Madras.14
As vaccination activities spread through the country, great inequities developed. Early operations were primarily restricted to easily accessible urban areas, which limited the impact of the vaccination effort. This was to be the lament for the next 150 years. Since evaluation was based on the number of vaccinations, not the percentage of the population protected, vaccinators could fulfill their assignment by returning to easily reached groups, such as schoolchildren in urban areas, to give them repeat vaccinations. Vaccination activities were extended to villages only in response to specific reports of smallpox cases and deaths.
Some groups resisted vaccination, sometimes for religious reasons, sometimes because of their distrust of the government. R.W. Hunter noted in 1876 that the Biharis were particularly reluctant to be vaccinated.15 This was still the case one hundred years later, and Bihar was the last state in India where smallpox transmission was interrupted. Some areas of the country were late to be served. Hopkins reports that vaccination did not reach Kashmir until 1894. And, while the rich and the educated are often at the head of the line to receive health services, vaccinators would sometimes vaccinate lower caste persons first in order to demonstrate that the procedure was safe.16
Widespread vaccination requires a dependable source of vaccine. For three decades, the vaccine supply in India could be traced to the propagation of the virus from that first vaccination of Anna Dusthall in Bombay. In 1832, however, Dr. McPherson of Moorshedabad (Murshidabad) reported the discovery of cowpox in Indian
cattle, and with this he developed a new source for vaccine. This India-grown lymph was believed superior and it was distributed widely, “where it was speedily mixed with that previously in use.”17
A dizzying array of vaccination procedures were used in nineteenthcentury India. Some vaccinations were given from person to person. Some vaccinators took inoculated calves with them to the site of vaccinations and applied the lymph directly from calf to human. Experiments were even attempted using goats and donkeys as vectors for the vaccine. Techniques for applying vaccine also varied, ranging from minor abrasions of the skin to deep incisions into which the material was placed. Vaccination locations varied from sites on the arm that would be familiar today to “the inner side at the bend of the elbow” or “the base of the right thumb in males and the left in females.”18 Because the vaccinia virus was viable only for a period of days, attempts were made to store it in vials or ampules with a wide variety of preservatives.
It is often thought that British colonial administrators imposed a vaccination program across India that was stymied by the people’s resistance to it. Hopkins relates a story of Indian priests at Benares who told of an old prophecy that India would expel the British through the leadership of a black child with white blood. Vaccination, the priests charged, was how the English intended to find that child to kill him.19
However, an exhaustive study of the colonial records suggests that, at least in the nineteenth century, the program was largely hampered by technical difficulties.20 These included the lack of a reliable vaccine (which undermined confidence in the program when people were vaccinated and later got smallpox), the problems of getting calf or human lymph to the area for vaccination, and the painful procedures used to introduce the virus. The program was also slowed by official discord, such as the constant tension between the desire to make local areas responsible for their own protection and reluctance at the central level to release control, the deliberate sabotage of the program by persons who were not convinced it was efficacious, and the pervasive foibles of those jockeying for power.
By 1898, some of the technical difficulties had been solved. Bovine lymph had largely replaced the use of human lymph in all provinces. Vaccinations were conducted either directly from calf to arm or with lymph preserved in tubes, either alone or mixed with glycerin, lanolin, or Vaseline. The State Vaccine Institute in Patwadangar (Uttar Pradesh) was established in 1904, and soon most provinces had a central vaccine depot for the manufacture of animal-derived vaccine.
The British government required that records be kept on smallpox rates, vaccination rates, and program efforts. A summary of countless pages of depressing statistics suggests that more than half a century after the introduction of the smallpox vaccine, the disease continued its relentless decimation of humanity in India. The effect of vaccine could be shown in specific areas, but for various reasons the disease was more than a match for the best efforts of health authorities on a national level.
In a 1909 publication, S. P. James attempted to show the vaccine’s effectiveness by charting the decline of smallpox, over ten-year periods, in the provinces of Bombay, the Punjab, and the United Provinces of Agra, Oudh, and Berar, an area he called “well-vaccinated British India.”21 The area had a recorded population of 137 million in the 1901 census. While the decline is obvious, the limited impact of almost a century of preventive efforts is just as evident. Even in the nineteenth century, the science of the day was far ahead of the ability to use it effectively.
To all of this must be added the competition between variolation and vaccination. The results of variolation were known and observable. When a village was variolated, a large percentage of residents would get a mild case of smallpox and the villagers then knew that as a group they were protected. With vaccination, on the other hand, the vaccine was not always reliable, and the occurrence of smallpox cases in previously vaccinated persons was general knowledge. Variolation also had the advantage of religious association. It was both a medical and a religious ceremony that included offerings to the goddess of the disease. Even though variolation caused a certain percentage of deaths, many preferred it over vaccination.
Table 1
Smallpox deaths in well-vaccinated British India, 1868–1907
Years
Deaths
1868–77
1,308,737
1878–87
1,242,797
1888–97
747,590
1898–1907
478,843
SOURCE: S.P. James, Smallpox and Vaccination in British India (Calcutta: Thacker, Spink and Co., 1909).
In the first half of the twentieth century, smallpox control efforts in India relied heavily on vaccination drives and isolation of patients.22 However, compulsory programs often simply stiffened any existing resistance, making it harder to get children vaccinated and turning health workers into half-hearted enforcers. A report from Madras indicates that many people were listed as “left the town,” which was simply a way of avoiding vaccination. The net impact of compulsory vaccination was an increase in falsification of the records. Attempts to enforce compulsory vaccination resulted in a lot of energy expended for little gain. A 1920s report from the Punjab indicates that 10,500 notices were filed in Lahore against parents who had not vaccinated their children. Only 49 made it to court, which resulted in 18 additional vaccinations. In another report from Jabalpur, in Madhya Pradesh, 1,502 reports for noncompliance led to an additional 5 vaccinations after court trials. Isolation of patients, while effective in theory, also increased the likelihood that families would hide family members with smallpox to avoid being separated from them.
Increasingly, medical authorities concluded that widespread vaccination was required. Yet the disparity in vaccination between urban and rural areas remained a significant obstacle. Rural populations tended to distrust imposed remedies, and rural health workers often resisted the introduction of new vaccines and operating techniques, especially when the additional training was at their own expense. Despite all of the problems, the number of vaccinations increased in the first half of the twentieth century. While mortality statistics for smallpox were as high as 1,000 to 2,000 per million people per year during the three decades between 1870 and 1900, they decreased to highs of 600 per million per year between 1900 and 1925, and finally dropped to about 100 per million per year by 1950. These are high rates for a country to tolerate from a single devastating yet preventable cause. A comparable phenomenon is twentieth-century America’s acceptance of lung cancer death rates of 1,300 to 1,500 per million, year after year, because of widespread tobacco use, a situation preventable through education.
Annual vaccinations increased steadily during this period and by the 1940s far exceeded the birth rate, yet 50 percent of smallpox deaths occurred in children under ten years of age. Clearly, the problem was not in the number of vaccinations delivered, but in who was receiving the vaccine. Vaccinators continued to return to easy-to-reach groups year after year, thereby providing superior immunity to some groups while other groups remained totally vulnerable.
In 1946, a report released by the Government of India listed smallpox, cholera, and plague as the three major epidemic diseases and reported that according to the League of Nations, India had the highest incidence of smallpox among all countries for which information was available. The report also noted that the continuing high rates of smallpox deaths in young children revealed the current program’s inadequacy, since a single vaccination in infancy could provide almost total protection during childhood.23
At the time of its independence, India was saddled with the highest smallpox incidence in the world. During the next quarter century the country would record over four hundred thousand deaths. If Basu is correct in assuming that only 1 percent of actual deaths were reported, the number of deaths was more like 40 million citizens.24 Would the perception of the power of the Goddess yet win?
NATIONWIDE PROGRAMS
In June 1958,
when the World Health Assembly passed the resolution to eradicate smallpox from the world, India responded by forming an expert committee of the Indian Council of Medical Research to suggest the methods to be used in India.25 The committee called for simultaneous action to be taken in all parts of the country. Noting the shortcomings of previous campaigns, the committee made several recommendations: setting up systems for compulsory registration of vital statistics, with punishments for those responsible for lapses; a Central Infectious Disease Control Act to ensure national uniformity; a central reference laboratory to provide quality control for vaccine production; a national smallpox eradication program to vaccinate the entire population within three years; and pilot projects in each state to develop the necessary procedures. The committee noted the periodicity of epidemics and the seasonal nature of the disease, but did not suggest using seasonality as a means of improving control procedures—even though Brahmin variolators had demonstrated that concentrating their efforts during the periods of low transmission was an effective means of reducing spread during periods of high transmission.
Pilot projects were initiated in each state, and in October 1962, the Government of India launched a nationwide program. Within five months, the entire country was involved in an attack phase, scheduled to extend for two to three years. As in other smallpox eradication plans throughout the world, the objective was mass vaccination, with three years to complete the attack phase and 80 percent coverage during that time—even though there was no scientific evidence showing the efficacy of these three goals. This stage was to be followed with a maintenance phase during which those missed in the attack phase would be vaccinated.
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