By the mid-1970s, India’s smallpox eradication campaign had been grinding for over a decade. But the virus was still spreading beyond control. It was time to take a new, more targeted approach.

This strategy was called “search and containment.” Teams of eradication workers visited communities across India to track down active cases of smallpox. Whenever they found a case, health workers would isolate the infected person then vaccinate anyone that individual might have come in contact with.

Search and containment looked great on paper. Implementing it on the ground took the leadership of someone who knew the ins and outs of public health in India.

Episode 2 of “Eradicating Smallpox” tells the story of Mahendra Dutta, an Indian physician and public health worker who used his political savvy and local knowledge to pave the way to eradication. Dutta’s contributions were vital to the eradication campaign, but his story has rarely been told outside India. To conclude the episode, host Céline Gounder and epidemiologist Madhukar Pai discuss “decolonizing public health,” a movement to put leaders from the most affected communities in the driver’s seat to make decisions about global health.

The Host:

In Conversation With Céline Gounder:

Voices From the Episode:

Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 2: Do You Know Dutta? Air date: Aug. 1, 2023 

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast. 

TRANSCRIPT 

Céline Gounder: 

This season, the “Epidemic” podcast is about the eradication of smallpox in South Asia. And to understand the breakout public health strategy that ultimately made eradication possible, we’re taking a quick detour … to West Africa. 

[Nigerian music begins to play.] 

Céline Gounder: It was 1966 — and Bill Foege found himself in Nigeria. The young physician and epidemiologist from Iowa was a long way from home — but in good company as part of a team of health workers sent to the region by the CDC [the Centers for Disease Control and Prevention]. Their mission was to vaccinate as many people as possible to stop smallpox. 

They traveled from one remote location to the next on electric bikes. [Electric bikes whir.] To coordinate the work and respond quickly to each new outbreak, they had two-way radios. [Radio static crackles.] 

[Music fades to silence.] 

Bill Foege:  On Dec. 4, 1966, I got a message saying, “I think we have smallpox. Could you come and look?” 

We went to the place, 8 miles off of a road, and it was immediately clear that the first person I saw had smallpox. And so, we started looking at: What did we have in the way of vaccine? 

Ordinarily, you would’ve done a mass vaccination campaign around the area. 

Céline Gounder:  At the time, the standard procedure was to vaccinate every single person in the region. But there was a problem: There wasn’t enough vaccine. Bill was still waiting on a big shipment. Without enough doses to vaccinate everyone, his team had to break protocol and get creative. 

Bill Foege:  We knew what we should do, but we couldn’t. So, at 7 o’clock that night, with maps in front of me, I divided the area and sent runners to the villages to see if they had smallpox. Twenty-four hours later, we got back on the radio [radio static], and now I could pinpoint the exact villages where there was smallpox. And we used the rest of our vaccine on those areas. 

[Music begins.] 

Bill Foege:  Much to our surprise, smallpox simply stopped in weeks. We just were so fortunate — so lucky that with our limited vaccine, we were able to hit the right people. And by July, we were working on the last outbreak in all of eastern Nigeria. 

Céline Gounder:  The health workers began to wonder: Could this approach also work in other parts of the world? The new vaccine strategy — the innovation that Bill and his team stumbled upon, out of necessity — came to be known as “search and containment.” 

That meant …  

First searching for anyone with an active case of smallpox. 

Then isolating the infected person. 

And finally, tracking down and vaccinating everyone that person had come into contact with. 

It worked in West Africa. Could it work in South Asia? 

[Music fades to silence.] 

Céline Gounder:  Getting locals there to adopt search and containment was going to take an ally, a leader with a big personality who knew the ins and outs of public health in India. Someone who could make things happen. Someone whose story you’ve probably never heard. 

Yogesh Parashar: Things look very rosy and very nice in a textbook. You never get the feel of what actually happened, how much sweat it entailed, what blood it entailed. 

Céline Gounder: I’m Dr. Céline Gounder and this is “Epidemic.” 

[“Epidemic” theme music plays then fades to silence.]  

[Music begins.] 

Céline Gounder:  By 1973, countries from Nigeria to Brazil to Indonesia had recorded their final cases of smallpox. But in India, the campaign to end the disease was still grinding along. The population was roughly 600 million people — and the goal to vaccinate every single person in the country was daunting. 

Epidemiologist Bill Foege was older now — in his late 30s — and leading the CDC’s global program to eradicate smallpox. 

He turned his attention to Bihar, a state in eastern India. It was the biggest smallpox hot spot in the world. There, Bill found an ally and a good friend in another physician, a man named Mahendra Dutta. Mahendra was in charge of the smallpox eradication program in Bihar. 

[Music fades to silence.] 

Yogesh Parashar:  He had a booming, loud voice. 

Céline Gounder:  That’s his son Yogesh Parashar, a pediatrician living in Delhi. 

Yogesh Parashar: My father was known for his honesty. He would help people. He had that nature. 

Céline Gounder: Mahendra Dutta died a few years ago. And Yogesh was just a boy during the eradication campaign. But his father shared stories from his years in the trenches fighting smallpox. And there was no battle bigger — or more lifesaving — than persuading the vaccinators to change their way of doing things. 

After a decade of mass vaccination, smallpox raged on. Yogesh says his father could see that the strategy wasn’t working quickly enough to stop the virus. 

Yogesh Parashar:  The standard way of doing things is not going to get us anywhere. Being nice, doing the right way, is not going to get the disease away. 

Céline Gounder: It was time to try something new. But getting India to adopt search and containment would prove challenging. 

Yogesh Parashar:  People who were trained in the previous school of thought could never believe that smallpox could be got rid of in this strategy. 

Céline Gounder:  Luckily, Mahendra could be very persuasive. 

Yogesh Parashar: My father did all the dirty work. He got enemies also in the process, I’m sure he did, but that is what he did. 

[Music begins.] 

Céline Gounder:  Mahendra Dutta was a gifted political strategist who built relationships with magistrates and commissioners throughout his work in public health. He was an insider who moved comfortably through the halls of power in India. 

Once, over dinner and a glass of whisky — Chivas Regal, to be specific — a senior official told Mahendra to come to him in the future if he ever needed a favor. Later, when it was time to build support for search and containment, Mahendra knew exactly how to cash in on that promise. 

Yogesh Parashar:  My father gifted him the Chivas Regal. 

“Now do you remember? You had told me that if I need any help, I should come to you. And here I am asking for help now.” This is how he did it. 

Céline Gounder:  You might call it “Dutta diplomacy.” 

[Music fades to silence.] 

Céline Gounder: Using charm and his extensive personal network, Mahendra recruited a staff of workers dedicated to the new strategy of search and containment — instead of trying to change the minds of people invested in the old ways of doing things. 

Yogesh Parashar:  So, practically, a parallel health system was set up. 

Céline Gounder:  The stakes were high. 

Yogesh Parashar:  Any outbreak was an emergency, because if you don’t move within hours and contain it, you do not know how many contacts will be there, how much it would spread, and your work would increase exponentially. 

[Suspenseful music begins.] 

Céline Gounder: Instead of waiting for smallpox cases to be reported, the workers headed out into the community to look for them. 

Bill Foege:  At first, we went and we talked to the village headmen, the teachers, and some children. And gradually, we went from that to actually going house by house in every village. 

Céline Gounder: But some cases were still falling through the cracks. 

Bill Foege:  And so, we developed secondary surveillance teams who would go around to the markets with a smallpox identification card. 

Yogesh Parashar:  There were WHO [World Health Organization] cards, which had photographs of cases of smallpox, their face, their body, and so on. So, the people would go out and ask the students, ask the people in the market, “Have you seen such a person with this kind of an illness?” This was one way of actively searching. 

Céline Gounder:  Everyone was willing to help. 

Yogesh Parashar:  The vehicle driver would also ask. Why would the foreign epidemiologist ask? The vehicle driver will talk in the local language: “OK, I’m looking for this.” They will tell him, “Yes, this is here.” 

Céline Gounder:  And, as soon as a case was identified, a team of containment workers would spring into action, isolating the patient, tracking down their recent contacts, and vaccinating anyone they could have transmitted the virus to. 

[Suspenseful music fades to silence.] 

Céline Gounder:  By 1974, the scale of the smallpox surveillance operation was gigantic. Over 100 million households across India were visited every single month in the search for active cases. Over 130,000 field workers were mobilized. 

Bill Foege:  At that point, we were having 1,500 new cases of smallpox a day in Bihar. 

Céline Gounder:  To manage all these moving pieces, the workers documented their efforts meticulously. 

Bill Foege:  I mean, you can’t imagine the millions of forms that we had. We had forms for everything. Forms for the containment team, forms for the assessors, forms for the watch guards. 

I often said, “We’ve just buried smallpox in forms.” 

Céline Gounder:  Search and containment was working in Bihar. Mahendra and Bill could finally see a path to eradication. 

Then, they hit a very public stumbling block that threatened to derail their work. 

[Sound of bomb exploding.]  Céline Gounder:  In May 1974, journalists from all over the world flooded into the country to cover a major news event. 

Here are a few lines from a New York Times article from that time. 

[Voice actor reading a headline from the May 20, 1974, edition of The New York Times. An audio filter gives it a grainy ’70s newscaster’s sound. Typewriter sound effects play.]  

Newscaster:  India conducted today her first successful test of a powerful nuclear device. The surprise announcement means that India is the sixth nation to have exploded a nuclear device. 

Céline Gounder:  The code name for the nuclear bomb test was Operation Smiling Buddha. And with it, the country joined a short list of superpowers. All eyes were on India. 

[Dramatic music begins playing.] 

Céline Gounder:  And … those international journalists on the hunt for interesting things to report came across another big story: Smallpox cases appeared to be exploding. 

Bill Foege:  And then suddenly the newspaper articles come out saying, here’s India working on nuclear weapons and they can’t even control smallpox. 

Céline Gounder:  In actuality, the new search-and-containment strategy was just a lot better at uncovering cases of smallpox. 

But those glaring headlines — accurate or not — put the eradication program in the spotlight. 

[Dramatic music fades to silence.] 

Céline Gounder:  Indian health officials were worried. And they threatened to pull their support for search and containment. 

The famous Dutta diplomacy was about to be put to the test … 

Bill Foege:  The minister of health for all of India came to Patna, and Mahendra Dutta went to the airport to meet him. 

Yogesh Parashar:  He said, “I have to address a meeting, and it would be difficult to talk to you separately. So why don’t you get into my car?” 

Céline Gounder:  During the ride, the minister of health told Mahendra that he was on his way to a press conference to announce that the smallpox program would switch back to the strategy of mass vaccination. 

To Mahendra, giving up on search and containment meant giving up on their best shot at eradication. 

Bill Foege:  And that’s when Mahendra Dutta said, “Before you do that, you have one more thing to do.” And he said, “What’s that?” He said, “You have to fire me.” 

Yogesh Parashar:  My father tells the minister that “if we are going to follow vaccinating everyone, then I think I should give you my resignation.” 

Bill Foege:  And the minister was irate. He said, “Do you know who you’re talking to?” And he said, “I do. And that’s how important this is.” 

Céline Gounder:  Mahendra told him the latest figures. He explained how the team was finally slowing the virus — that things were coming under control. 

And the health minister listened. 

Yogesh Parashar:  And, within a few minutes, when they had reached the venue, the health minister was addressing the other officials, and he said, “OK, we have a new strategy of search and containment, which is very successful, has been tried in a number of countries, and we will bring forward this strategy and get rid of the disease.” 

[Triumphant music begins playing.] 

Bill Foege: All he did was praise the smallpox workers for what they had done, never said a word about switching back to mass vaccination. 

That’s how close we came, I think, to losing the program in India. And, of course, if we lost it in India, we lost it everyplace. 

Céline Gounder:  If India, with its population of over 600 million people, failed to stop smallpox, then the virus would have remained a threat to the entire world. 

Yogesh Parashar: My father has done the dirty job of saying what is to be said and got away with it. 

He diplomatically bought time, allowed the search and containment to go on and get “smallpox zero.” 

[Triumphant music fades to silence.] 

Céline Gounder:  While some of his American collaborators have been celebrated around the world for their work to end smallpox, Mahendra Dutta’s story — and his contributions — aren’t well known outside of India. 

But we managed to find this recording of his voice …  

[Brief pause.] 

Mahendra Dutta:  In public health, community approach, your conviction, your devotion, and team effort, that’s what matters the most. 

Céline Gounder:  That’s Mahendra Dutta in 2008, when he was in his late 70s. He and Bill Foege sat down together to reminisce about the history of smallpox eradication as part of a CDC event. 

The two old friends reflected on what they’d learned together. 

Bill Foege:  I think that’s the lesson of smallpox in India, that the team worked as a unit. It was a coalition in truth. 

Mahendra Dutta:  Devoted efforts, team efforts always matter in community health work.  

[Music begins playing.]  Céline Gounder:  Search and containment was one of the public health innovations that made eradication possible — that, and the collaboration among international health workers and local public health leaders. 

Here, we followed the story of Mahendra Dutta, but there were many names — thousands — working together toward a common goal. 

[Music begins.]  

Céline Gounder:  I have a friend who thinks about that a lot. Madhukar Pai is a community medicine physician, an epidemiologist — and he teaches global health. 

His big thing is he wants rich countries to stop trying to use their own lens to solve health problems around the world. He says that just doesn’t work. 

He’s calling for a “radical shift.” But … 

Madhu Pai:  It is hard to give up on power and privilege. No powerful person wants to ever give it up. 

Céline Gounder:  More from Madhu after the break. 

[Music fades to silence.] 

Céline Gounder:  Wiping out smallpox nearly 50 years ago required the skill of thousands of local people who are largely unrecognized in any history book — or podcast. 

Putting locals in the driver’s seat is one part of a growing movement to “decolonize” public health. 

That term might sound wonky. But Madhukar Pai, a professor of epidemiology and global health at McGill University [in Montreal], says decolonizing public health is exactly what’s needed to get to health equity around the world. 

But Madhu is frankly pretty pessimistic about the current system. 

Madhu Pai:  I sometimes wonder how the hell did we eradicate smallpox. I mean, today, I don’t think we would have. Honestly, if there was a virus like smallpox today, there’s zero chance of eradicating it. 

Céline Gounder:  So what was it about smallpox eradication that allowed us to do it? 

Madhu Pai:  I think those were simpler days, right? And then WHO said, you know what? Let’s just get all together and just help end this disease. That collaboration was unprecedented in smallpox. 

But I think it was, in the end, remarkable numbers of people, you know, essentially armies of community health workers, vaccinators, front-line staff, field workers. And that was a mobilization kind of an effort that I think we definitely tried to do during covid. But probably not as unified as we could have been. 

Céline Gounder:  We did try to do something like that. It was called COVAX. 

It was an alphabet soup of international groups — from Gavi to the WHO — that wanted to pool buying power and scientific resources. 

COVAX was an attempt to make sure that there was covid vaccine for the whole world. 

So … why did COVAX fail? 

Madhu Pai:  First of all, I think COVAX was conceived by “global north” white people, and it was conceived with all good intent, but essentially the “global south” was left behind even in the design of COVAX. Now that in essence is global health, right? That is, privileged people in the global north are constantly making decisions, thinking that we know best. 

Céline Gounder:  In case our audience isn’t familiar with that term, when Madhu says “global north,” that’s a shorthand for talking about wealthy industrialized nations. 

Madhu Pai:  Relying on the global north time and time and time again is doomed as an idea because we’ve seen there is no end to our greed and myopia and self-centeredness. 

Céline Gounder:  What would that have looked like? Centering international efforts to provide vaccines to low-income countries? 

Madhu Pai:  To me, centering on them rather than us and saying, “What do you need from us to succeed in your plan?” Right? “How can we be allies to you?” We need to get behind that and respect the desires and the aspirations of global south countries. 

If there is a new pandemic and there’s a new vaccine or medicine, that technology should be transferred very quickly. 

That’s what allyship genuinely is about. And that’s what our country should have done. We could … should have been allies as countries, right? We should have given the vaccine recipe. We should have helped out way better with the vaccine donation — the opportunity of a lifetime to be good allies. But we left it on the table. 

Céline Gounder:  If you had to give a grade to our global health response to covid, what would it be and why? 

Madhu Pai:  I would probably give it a “D” because I think, as humankind, we genuinely failed. There’s no reason at all so many people should have died. That’s inexcusable. The fact that 2.3 billion people, mostly in low-income countries, middle-income countries have not received even one dose is a very telling statement on how this all unfolded. That’s political failure. It’s got nothing to do with science, technology, or availability, or money. 

Céline Gounder:  So let’s say another pandemic hits us tomorrow. How is that gonna play out, then? 

Madhu Pai:  Exactly like it played out in covid, I do not expect anything different, honestly. Which is bloody sad, really. 

Céline Gounder:  You said before that the big global health programs have good intentions. So, what should they be doing differently? 

Madhu Pai:  Global health, as you know, is full of these examples where the global north person always gets the, you know, the shining credit and the medal on the wall. 

We need to kind of flip the switch and re-center global health away from this, what I call default settings in global health, to the front lines. Right? People on the ground. People who are Black, Indigenous. People who are in communities. People who are actually dealing with the disease burden. People who are dying of it, right? People who have actually lived experience of these diseases that we are talking about, right? Having them run it is the most radical way of reimagining and shifting power and global health. 

Céline Gounder:  As Madhu and I were talking, he reminded me about Bill Foege. He’s the American eradication worker from Iowa we already met in this episode. The one who worked closely with local partners like Mahendra Dutta. 

But near the end … he stepped out of the spotlight. 

I asked Bill about this: 

Céline Gounder:  You left India before smallpox was declared eradicated. And as I  understand it, that was important to you to no longer be in the country at the time. Why is that?  

Bill Foege:  I had the feeling that it should be an Indian victory. That foreigners should be happy and pleased that they had a chance to be part of it but don’t get carried away with being celebrated. 

Madhu Pai:  People like Foege are the exception in global health and not the norm. Finding ways to completely disappear and then center on people who really matter, I think is a, is a great gift. 

The ability to do Dr. Foege’s ego-suppression work, uh, allyship work, that’s where the next frontier lies. And I’m not sure if we are ready for it, right? Because it is hard to give up on power and privilege, right? No powerful person ever wants to give it up. 

Céline Gounder:  So if you had a call to arms to your colleagues about preparing for the next pandemic, what would you say? 

Madhu Pai:  Yeah, I would say, anything that is led by global south, anything that is led by communities, must be on top of the agenda because that is how this is all gonna work. 

So I don’t think climate change, or conflicts, or covid will be magically solved by global north institutions or individuals. So, de-center, de-center, de-center away from us, and be good allies to the global south. 

Everybody’s agreed that we gotta do better, you know, we’ve got to decolonize global health. But it isn’t meaningfully moving the needle in the right direction. Because when rubber hits the road, our allyship only goes so far as just talking about it, which is not allyship at all in the first place. 

[“Epidemic” theme music begins playing.]  

Next time on “Epidemic” …  

Bhakti Dastane:  We have to achieve “zeropox,” so it was our motto: “zeropox.”  

CREDITS   

Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions. 

Additional support provided by the Sloan Foundation. 

This episode was produced by Taylor Cook, Zach Dyer, Jenny Gold, and me. 

Our translator and local reporting partner in India was Swagata Yadavar. 

Taunya English is our managing editor. 

Oona Tempest is our graphics and photo editor. 

The show was engineered by Justin Gerrish. 

We had extra support from Viki Merrick. 

Music in this episode is from the Blue Dot Sessions and Soundstripe. 

Audio of Mahendra Dutta via the Global Health Chronicles recorded at the David J. Sencer CDC Museum at the U.S. Centers for Disease Control and Prevention. 

We’re powered and distributed by Simplecast. 

If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show. 

Follow KFF Health News on Twitter, Instagram, and TikTok. 

And find me on Twitter @celinegounder. On our socials, there’s more about the ideas we’re exploring on the podcasts. 

And subscribe to our newsletters at KFFHealthNews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news. 

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.” 

[“Epidemic” theme music fades to silence.] 

Bill Foege:  It was great to work with you then, and it’s great to hear you reminisce now. 

Mahendra Dutta:  I’m also pleased that I’d worked with you. 

Credits

Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer 

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

Epidemic is a co-production of KFF Health News and Just Human Productions.

To hear other KFF Health News podcasts, click here. Subscribe to Epidemic on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

In the mid-’60s, the national campaign to eradicate smallpox in India was underway, but the virus was still widespread throughout the country. At the time, Dinesh Bhadani was a small boy living in Gaya, a city in the state of Bihar.

In his community many people believed smallpox was divine, sent by the Hindu goddess Shitala Mata. In Bihar people had misgivings about accepting the vaccine because, Bhadani says, they did not want to interfere with the will of the goddess. Others hesitated because making the vaccine required using cows, which are sacred in the Hindu religion. Still others hesitated because the procedure — which involved twirling a barbed disk into a patient’s skin — hurt.  

But when Bhadani was 10 years old, he saw the body of a school friend who had died of smallpox. The body was covered in blistering pustules, the skin not visible at all. 

Soon after, when eradication workers came to town, young Bhadani remembered his friend, gritted his teeth, and agreed to get the painful vaccine.  

Variola major smallpox was deadly and highly contagious. Infected people often died within two weeks — many of them young children. Those who survived could be left severely scarred, infertile, or blind. 

Episode 1 of “Eradicating Smallpox” explores the layered cultural landscape that eradication workers navigated as they worked to eliminate the virus. Success required technological innovations, cultural awareness, and a shared dream that a huge public health triumph was possible.  

To close the episode, Céline Gounder wonders how the U.S. might tap into similar “moral imagination” to prepare for the next public health crisis.

The Host

In Conversation with Céline Gounder:

Voices from the Episode:

Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 1: The Goddess of Smallpox Air date: July 18, 2023 

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast. 

TRANSCRIPT 

[street noises] 

Céline Gounder: 

It’s a hot, humid day in New Delhi. Little shops line the street — food stalls, a kite store, and a small, neighborhood temple nestled among them. And just outside the orange temple gate, a pile of flip-flops and sandals. 

[ringing bells and people murmuring] 

Céline Gounder: 

The temple bells are calling. So, I take off my shoes and head inside. The walls are covered in floral tiles, and all around me, people pray barefoot in the glow of the fluorescent lights. There are offerings of flowers and sweets in front of the statue of the elephant-headed Hindu god, Ganesh. And nearby a less familiar figure: the goddess Shitala Mata. 

She’s riding a donkey, with a pitcher of water in one hand and a broom in the other. She wears a fan on her head like a crown. There’s a garland of marigolds strung around her neck. Shitala Mata: the goddess of smallpox. 

[music change] 

Céline Gounder: 

I’m Dr. Céline Gounder. I’m an epidemiologist and infectious disease specialist. 

[music change] 

Céline Gounder: 

My dad grew up in a rural part of southern India, and his childhood there was shaped by relative poverty. Dad was the first person in his village to make it past the fifth grade, smart and fortunate enough to make it to a prestigious university. He came to the United States for grad school and became an engineer. 

But he told us stories of the big divides back home in India — in health, in education, in opportunity. Those stories shaped me. Those inequities are a big part of why I chose a career in public health. I became a physician, and over the years worked on infectious disease outbreaks all over the world — tuberculosis, HIV, Ebola, and of course, most recently, covid. 

Watching the United States respond to the pandemic got me thinking back to another disease that gripped the world … smallpox. In the 20th century alone, smallpox killed over 300 million people. But in one of the greatest success stories in science, medicine, and public health history, we conquered smallpox. Gone everywhere. 

In the summer of 2022, I traveled to India and Bangladesh to seek out that history. This podcast is the story of the final days of smallpox eradication in South Asia. But before we get to that, I want to share what I’m beginning to understand about the role smallpox played in people’s lives. 

[murmuring of people] 

Céline Gounder: 

That’s why I’m here at this temple. Smallpox was seen as part of nature, elemental; something so old, so ingrained in daily life, that it had a place among the gods. 

Rajendra Prasad Dhyani: 

[Rajendra Prasad Dhyani speaking in Hindi, overlaid with voice actor’s English translation] 

I am Rajendra Prasad Dhyani and I serve at the Shitala Mata Temple, Madangir, C First Block. You want to know about Shitala Mata, don’t you? 

Céline Gounder: 

There are lots of origin stories for Shitala Mata. 

[music fades in] 

Céline Gounder: 

The story the temple priest Rajendra told me starts like this: One day in a village, people were washing clothes. A goddess was wandering the town disguised as an old woman when someone threw scalding water on her. 

Rajendra Prasad Dhyani: 

[Dhyani speaking in Hindi, overlaid with voice actor’s English translation] 

She got blisters all over her body. She got on a donkey and started roaming around the village, screaming in pain. 

Céline Gounder: 

One of the villagers poured cold water on the old woman. She was magically healed and revealed her true form as the goddess Shitala Mata. 

Rajendra Prasad Dhyani: 

[Dhyani speaking in Hindi, overlaid with voice actor’s English translation] 

She said, “Anyone who suffers from a blistering disease, be it chickenpox or smallpox, if you give them food cooked the night before as my blessing, they will be cured.” 

Céline Gounder: 

Shitala Mata both gives smallpox and cures it. Her disease can be seen as a curse, a terrible illness, or as a blessing — an opportunity to rest and reflect. 

Rajendra Prasad Dhyani: 

[Dhyani speaking in Hindi, overlayed with voice actor’s English translation] 

She blesses people. She blesses them with peace of mind and calm. Sheetal means cool, so she soothes the mind and bestows devotees with peace of mind. She is the goddess of tranquility. 

Céline Gounder: 

What Shitala Mata represents in Indian culture is complex. 

[music ends] 

Céline Gounder: 

And defeating smallpox required appreciating and respecting that complexity. It also took medical advances, fresh ideas about epidemiology, unlikely partnerships, and the unwavering dedication of hundreds of thousands of health care workers. We have firsthand accounts from health leaders who were there, some who have never been heard outside of India and Bangladesh. 

I’m Dr. Céline Gounder and this is “Epidemic.” 

[music interlude] 

Céline Gounder: 

Today, it’s hard to even imagine what it was like to live in a world with smallpox, where, in the course of your daily life — riding a train, sitting in a classroom, going to work — you could catch a virus so deadly that it killed about 1 in 3 people. That was the death toll before smallpox vaccination became widespread: 1 in 3. And if you did survive, the scars left behind might haunt you for the rest of your life. I met up with someone who lived in those “before times,” when eradication was still a far-off dream. 

Dinesh Bhadani: 

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

My name is Dinesh Kumar Bhadani. I am a retired station manager in Indian Railways. Now, my age is 68 years. 

Céline Gounder: 

I met up with Dinesh Bhadani and his daughter Priyanka at their apartment in New Delhi. As we drank sweet pomegranate juice, Dinesh told me about growing up in the 1960s in Gaya, a small holy city in the eastern state of Bihar. Pilgrims from around the world traveled there to visit the temples. And in the Bihar of Dinesh’s youth, his hometown was one of the last hot spots for smallpox. Dinesh says diseases like smallpox, measles, mumps — they weren’t just a matter of bad luck. To many, they were the will of the gods. 

Dinesh Bhadani: 

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

People used to call all of these as some type of wrath from God. People did not consider them illness; people used to say they were divine wraths.  

Céline Gounder:  

Dinesh’s family home was enormous. It was hundreds of years old. Sometimes more than 50 people cooked together, ate together, and — with little ability to isolate — they got sick together. Especially during a smallpox outbreak. 

[music change] 

Voice actor speaking in English: 

There was an atmosphere of fear because the number of deaths had increased. 

Dinesh Bhadani: 

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

At that time, many people died, especially teenagers. A lot of young people died. 

Céline Gounder: 

Smallpox could spread quickly, traveling from person to person from a cough or a sneeze; through everyday family contact with contaminated bedsheets or towels. 

The first signs of infection were usually a high fever, headache, and sometimes vomiting and diarrhea. Then pustules filled with fluid appeared on the body — both inside and out. It was searingly painful. People often died within two weeks — many of them young children. Those who survived could be left severely scarred, infertile, or blind. 

A smallpox vaccine has been around since the 18th century, but that protection didn’t reach enough people, so smallpox thrived and continued to kill millions around the world. 

Dinesh says he remembers that, in Bihar, people had real misgivings about getting the vaccine. Some didn’t want to interfere with the will of the goddess Shitala Mata. Other people hesitated because of the vaccine itself. And the procedure could hurt. 

Dinesh Bhadani: 

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

They were afraid that it was painful. That’s why people would run away, like, “We will not take it.” 

Céline Gounder:  

Smallpox vaccinations in the 1960s really did hurt more than the quick shots we get today. Health workers dipped a rotating barbed disc into the vaccine solution and then twirled it into a patient’s skin. The vaccine entered the body through these open wounds. It was a brutal procedure. 

Dinesh Bhadani:  

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

It used to be very painful. It took more than one week to heal. 

Céline Gounder:  

But as more and more people fell ill, the calculus of fear began to change. For Dinesh, it happened when he was 10. A classmate died of smallpox. It was the mid-1960s. 

Dinesh Bhadani: 

[Bhadani speaking in Hindi] 

He was a very handsome boy. He was the most good-looking boy in our group. 

Céline Gounder: 

Dinesh was curious about what happened to his friend, so he went to see the body. 

Dinesh Bhadani:  

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

The skin was not visible at all. It looked like a person who got burned, whose entire skin had been burnt. There were blisters all over his body, and a foul smell was coming from his body. 

Céline Gounder: 

Dinesh was so terrified that he couldn’t sleep for three days. 

Dinesh Bhadani: 

[Bhadani speaking in a mix of Hindi and English, before the voice actor’s English translation begins] 

The fear that it created, after seeing him, after witnessing his death — fear spread among people, like, “Let’s take the vaccine so that we don’t have to face these kinds of deaths.” 

Céline Gounder: 

There was a vaccine camp at his school, and Dinesh lined up for his dose. Then health workers went house to house, knocking on doors to find any children they’d missed. In the end, Dinesh says, every student at his school was vaccinated. And that feeling of fear that gripped the community began to fade. School by school and town by town, health workers repeated this painstaking work across the state of Bihar. 

[music fades in] 

Céline Gounder: 

Decades after smallpox was eradicated, it was hard for people who had survived the disease to really leave it behind. 

[music fades away] 

Céline Gounder: 

Dinesh’s daughter Priyanka Bhadani says that when she was maybe 10 or 12 years old, she started noticing how the adults around her reacted to lingering smallpox scars. It was the 1990s by then. 

Priyanka Bhadani:  

I realized that a lot of people were not welcome in the house — a lot of people with those marks that smallpox left on their bodies. So, there’s this one uncle, who couldn’t get married till the time he was 45, 46, because he had these scars. 

Céline Gounder:  

Survivors like her uncle were isolated, sometimes cut off from society. Priyanka remembers a local businessman who experienced the stigma that often followed someone who’d had smallpox. 

Priyanka Bhadani: 

He loved one girl in the community; he wanted to get married to that girl. The girl was also in love with him, but then he got smallpox and the family refused, and his entire life was spent in proving himself to be worthy of the girl. So, he established a business, which was huge, for people to take notice of him. 

[music begins] 

Céline Gounder:  

Traveling around New Delhi and Pune, I met several older people with pockmarks on their faces, but this is the last generation with those scars. 

In 1980, the World Health Organization declared that smallpox was eradicated — wiped from the planet. It’s one of the greatest triumphs of science, medicine, and public health. But today, roughly 40 years after the disease was defeated, hardly any of my colleagues in public health have any living memory of smallpox, or the Herculean effort it took to eradicate it. 

We’re going back in time to consider that history. If we are to overcome current-day crises — from covid to climate change — perhaps there’s something we can learn from those bold leaders of the past. Generations before us imagined a world without smallpox when that goal must have felt like science fiction. 

adrienne maree brown: In science fiction, there’s questions that generally guide how we create. So, it’s “What if?” Like … “What if cars could fly? What if everyone had health care? What if?” And “If this goes on …” Where it’s like, “If this goes on the way it is, if nothing was to change, can we live with this?” 

Céline Gounder: 

Can we live with this? 

[music begins] 

Céline Gounder: 

What would it take to imagine a world with fewer covid deaths? When we come back, we’ll speak with social justice organizer and author adrienne maree brown. She’ll tell us what science fiction can teach us about dreaming up the next great public health triumph. 

[music fades away] 

Céline Gounder:  

Our reporting on what it took to eradicate smallpox has me wishing that our country had a bit more moral imagination as it faces covid and braces for the next public health crisis. Moral imagination is the idea that to solve big problems you have to think big; dream big. Then, you have to fuel those dreams with down-to-earth creativity, empathy, and commitment. Joining us is social justice organizer and science fiction author adrienne maree brown. 

adrienne maree brown: It’s really nice to be here and I’m grateful you’re approaching this topic, so let’s see what we can do. 

Céline Gounder: 

adrienne, whether you’re writing science fiction or organizing for social change, a lot of your work is about imagination. Over the course of my career, and I’m sure you’ve run into this too, of people saying some version of, “This is the way the real world is, or this is just the way it is.” 

adrienne maree brown: 

Mm-hmm. 

Céline Gounder: 

And they tell you that some changes aren’t possible, that some ways of doing things just don’t make sense. Where do you find the inspiration to think up, to dream up the worlds that are so wildly different from our present reality? 

adrienne maree brown: Saying that stuff is just the way it is, that’s one of the greatest ways that those who currently benefit from the way things are keep us from even imagining that things could be different. For centuries in this country, we were told that slavery was just the way things are, and that it could never be any different. And yet there are people in those systems who said, “This isn’t right. This isn’t fair. Something else is actually possible.” 

So a lot of the work of radical imagination, for me, is the work of saying, “Can we imagine a world in which our lives actually matter, and we structure our society around the care that we can give to each other, the care that we need?” 

Céline Gounder:  

And as part of this idea of radical imagination, I know that you really draw on science fiction as a way of helping us test out solutions to real problems. Is there an example from your fiction, maybe your new book, “Grievers,” of fiction helping provide solutions to real problems? 

adrienne maree brown: “Grievers” is the first in a trilogy of books, and in the beginning, the first novella, we have a plague that rolls out through the city of Detroit and stops people from being able to function in any way, and they’re really overcome with what appears to be debilitating grief. And when covid happened, I felt what I had been writing about in the book was in practice. And so, what is emerging in these books is how do we actually come up with plans for surviving changing conditions together? 

Céline Gounder: 

Well, one of the frustrations I’ve had as a doctor and epidemiologist working in the pandemic is that our leaders seem to think that our current covid death rates are acceptable, even though at the current levels we’d be looking at about a hundred thousand deaths per year. How can we influence change when many people in power aren’t willing to spend more money to save more lives? Especially when it comes to marginalized communities that have been hit hardest by covid. 

adrienne maree brown: Mmmm. I think what’s very difficult, and I think what you’ve been pointing to, is we’re in a situation right now where our economic structure works directly against every other aspect of our survival. I lost people to covid. I’m not OK with it; I don’t accept it. And it’s so heartbreaking because it’s like, your government could have protected you from this; your job could have protected you from this. Like there’s so many front lines that could be held that would protect our people. 

And I keep coming back to disability justice and disabled communities, ’cause that’s where I see some of the most interesting, hard work happening around this now. ’Cause they’re like, “It’s great that y’all are all trying to rush back into acting all normal. We literally can’t do that. We’re not willing to pay the cost.” And so, watching communities start to figure out how to navigate that with each other: How are disabled communities getting together? Why are we so willing to let so many people die unnecessarily rather than making the necessary pivots inside of our economic models and inside of our approach to community with each other? 

Céline Gounder:  

Early in the pandemic, it did feel like people were re-imagining things to some degree, like remote learning, you know, or how do you expand access to broadband or access to health care coverage or paid sick and family medical leave for everybody. But now we’re seeing fewer and fewer resources being allocated toward saving lives. People are feeling really beaten down in public health right now. We’re really at an all-time low in terms of morale. Where do you turn to for reminders that another world is possible, that there is hope? 

adrienne maree brown: What I have learned is that people cannot jump straight from crisis and despair to like [singing] “a whole new world,” right? You just — that’s not a leap you make. 

Each of us is carrying this small piece of this collective grief. These are not numbers. They’re people. They’re mothers and fathers, grandparents, children. They’re people that we loved. And we want to live a life and structure a world that honors what we’ve lost as well as what we’re dreaming of. What does that grief make us want to fight for? What does it make us want to dream up? What does it make us want to open room for? 

Céline Gounder: 

adrienne, it’s interesting. We’re addressing some of the same issues, but with very different tools. And I’m curious, do you have any final questions for me? 

adrienne maree brown: I think my question for you would be, what do you feel like are the most exciting innovations that you wish people understood and knew were in development around this? 

Celine Gounder: Oh, interesting. I think it’s not necessarily new innovation. 

adrienne maree brown: Mm-hmm. 

Céline Gounder: 

Sometimes it’s stuff that we already have and we just haven’t scaled up and used. It’s not enough to invent something new. You have to take it to scale. 

adrienne maree brown: Yes. 

Céline Gounder:  

And so, whether that is cleaning the air or paid sick and family medical leave, you know, as many as 15, 20 million people might be losing their Medicaid. Could we imagine everyone having health care or access to health care? What would it take to get there? Um, I think that’s where I’d like to see innovation, is actually in our ability to imagine that. 

adrienne maree brown: I love that. These are things that we actually know work, and it’s how do we get people to be in the practice of implementation. So thank you for sharing on that. 

Céline Gounder:  

Thank you, adrienne. I’ve really enjoyed our conversation. 

adrienne maree brown: I’m really glad we got to speak. Thank you, Céline. 

[music begins] 

Céline Gounder:  

That was adrienne maree brown, author of the “Grievers” novels, a speculative fiction series about survival and hope in a pandemic-stricken Detroit. 

“Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions. 

Additional support provided by the Sloan Foundation. 

This episode was produced by Zach Dyer, Jenny Gold, Taylor Cook, and me. 

Taunya English is our managing editor. 

Oona Tempest is our graphics and photo editor. 

The show was engineered by Justin Gerrish. 

Voice acting by Ashish Mukerjee and Jatinder Singh Taneja. 

Music in this episode is from the Blue Dot Sessions and Soundstripe. We’re powered and distributed by Simplecast. 

If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show. 

Follow KFF Health News on Twitter, Instagram, and TikTok. And find me on Twitter @celinegounder. On our socials there’s more about the ideas we’re exploring on the podcasts. 

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news. 

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.” 

[music fades to silence] 

Credits

Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Chris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

Epidemic is a co-production of KFF Health News and Just Human Productions.

To hear other KFF Health News podcasts, click here. Subscribe to Epidemic on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).