Bangladesh: Where Pestilence Died
"For those who have suffered, recovered, or died from smallpox, for those who have been isolated behind bars during a storm of ill contagion, for those who untiringly led or participated in this movement to uproot smallpox infection: we are all as one, and we are all now free of this fight and this fear of death and discrimination.
Our children can now breathe free." --Carol F. Music (Ogden, 1987, p. vi)
The last person to naturally contract smallpox (i.e., not through a laboratory accident) was a young Somali man named Ali Maow Maalin, who came down with and then recovered from the disease in October 1977. However, Maalin dealt with a less deadly strain of smallpox-- Variola minor. The last person to naturally contract the more deadly strain of smallpox-- Variola major-- was a Bangladeshi toddler named Rahima Banu, whose case was reported to regional officials of the World Health Organization (WHO) in October 1975. She made a full recovery and all villagers who had come into contact with her family were vaccinated as a precaution.
Bangladesh was one of the last fronts in the campaign to eliminate smallpox. By April 1971, smallpox was eradicated entirely from the Western Hemisphere when the last case was reported in Brazil. By 1972, smallpox was present in only six countries, and two countries were nearing eradication. Botswana was dealing with a minor reemergence that amounted to fewer than 30 cases, and all of Nepal's recent cases were brought over from India. That left the aforementioned India, plus Ethiopia, Pakistan, and Bangladesh (then known as East Pakistan) as the only nations with endemic smallpox. Fortunately for health officials, smallpox persisted only in limited geographic sectors of these countries, so their work would not require them to sweep the entirety of these populous countries.
Aiding the final legs of the marathon to eradicate smallpox was a new medical development: the bifurcated needle, a vaccination needle that would collect the right liquid dose between its two prongs when dipped in vaccine. It was easier and less cumbersome to use than the previous go-to tool for mass vaccination-- jet injectors-- and the needles were cheaper to manufacture en masse. Bifurcated needles also could be reused after being boiled in water, and the fact they always collected the right dose of vaccine was a great assurance to administrators concerned about unnecessarily depleting their stocks.
Nationalist Poster Depicting Pakistani Army Atrocities in 1971
Bangaldeshi poster depicting atrocities committed by Pakistani soldiers during the Bangladesh Liberation War of 1971
In 1971, Bangladesh reported it had eradicated smallpox within its borders, but when the country seceded from Pakistan in December of that year, civil strife challenged this achievement. The beginning of the Bangladesh War of Independence saw an estimated 10 million people flee across the border from Bangladesh to India, where they crowded together in refugee camps. As these refugees gradually returned home, smallpox returned with them. A May 1972 survey of one heavily infected subdistrict reported about 1% of the population there had been infected and over 90% of these cases were not reported to the government. The lack of reporting was attributed to an accountability policy that held vaccinators personally responsible for smallpox outbreaks and punished them when they reported cases within their jurisdiction-- a policy that was scrapped at the urging of international officials. In fact, in August 1974, the Bangladeshi government started offering a 50 taka ($6) reward to citizens who reported new outbreaks of smallpox in villages. (Admittedly, this effort was hindered by some frontline health workers who avoided advertising the reward in order to collect the money for themselves).
Panel meeting for Bangladesh smallpox eradication project
Photo taken by Stanley O. Foster of a monthly meeting of an international panel of experts contributing to the Bangladeshi smallpox eradication program
Indeed, the ultimate success of smallpox eradication in Bangladesh was aided by efforts by health officials to identify and correct factors that resulted in containment failures. For instance, when health officials learned of a local superstition that held that you could visit infected friends and relatives safely by entering their house through their back door at midnight resulted in guards beings posted outside infected households to ensure nobody broke quarantine. Likewise, when health officials became aware that frontline health workers were unwilling to live in infected villages to oversee containment, local villagers were hired to maintain quarantine, vaccinate their neighbors, and identify new cases of smallpox. Having trained associates in the affected villages who could also provide them with food and lodging eventually made health workers feel comfortable enough to establish themselves in the villages. This public participation would prove especially critical in the final stages of eradication, with 44% of the final 119 outbreaks reported by members of the public, and the last case of smallpox being reported by an eight-year-old girl.
Human factors were also essential to the final success of smallpox eradication. Dr. A.G. Rangaraj (the first Indian physician parachutist, a veteran of the China Burma India Theater in World War II, and an advisor for smallpox eradication efforts) claimed that his military training had taught him to remain optimistic even when a scenario appeared to objectively unwinnable, and this spirit enabled him to keep cheering on his colleagues even when circumstances in Bangladesh appeared dire. Esprit de corps was also supported by a field mentoring program for new recruits and a radio system that connected workers across the country and enabled weekly conference calls.
Rahima Banu
1975 photograph taken by Stephen O. Foster that depicts 2-year-old Rahima Banu, whoc contrated the last naturally occurring case of variola major
Rahima Banu in 2000
Photo credited to Stephen O. Foster depicting Rahima Banu (top left) as an adult alongside her husband and children
The aforementioned factors and collaboration between international and national health officials once again turned the tide against smallpox by October 1974, but the last two infected subdistricts were hit by floods that month, ruining crops, destroying villages, and causing a famine that drove the affected to cities, reintroducing smallpox there. A contemporaneous slum clearance initiative further increased homelessness and the spread of smallpox. The declaration of a national emergency helped mobilize national resources to meet the growing crisis, matched almost evenly by increased international aid. In the spring of 1975, health workers started employing a house-to-house survey strategy pioneered in India. 12,000 health workers were tasked with checking 1,000 houses each and asking the residents if they had seen anyone recently with a rash matching a picture of a smallpox patient. Despite the enormous scope of this survey campaign, each survey cycle was completed in 5-9 days, and 12 million homes were targeted over the course of five survey cycles. This aggressive push reduced the number of villages with smallpox cases from 1,280 in April 1975 to 150 in July. In November 1975 Rahima Banu was declared smallpox-free: variola major had gone extinct in the wild.
