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.